Scalp reconstruction: A 10-year retrospective study

Accepted Manuscript Scalp reconstruction: A 10-year retrospective study D. Steiner, M.D., A. Hubertus, A. Arkudas, M.D., C.D. Taeger, M.D., I. Ludolph, M.D., A.M. Boos, M.D., M. Schmitz, M.D., Dr. med. Dr. h.c. R.E. Horch, M.D., Head: Univ.Prof., Dr. med. J.P. Beier, M.D., Prof. PII:

S1010-5182(16)30312-2

DOI:

10.1016/j.jcms.2016.11.023

Reference:

YJCMS 2540

To appear in:

Journal of Cranio-Maxillo-Facial Surgery

Received Date: 31 July 2016 Revised Date:

14 October 2016

Accepted Date: 30 November 2016

Please cite this article as: Steiner D, Hubertus A, Arkudas A, Taeger CD, Ludolph I, Boos AM, Schmitz M, Horch RE, Beier JP, Scalp reconstruction: A 10-year retrospective study, Journal of CranioMaxillofacial Surgery (2017), doi: 10.1016/j.jcms.2016.11.023. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

ACCEPTED MANUSCRIPT Scalp reconstruction: A 10-year retrospective study

Steiner D., M.D., Hubertus A., Arkudas A., M.D., Taeger C.D., M.D., Ludolph I., M.D., Boos A.M., M.D., Schmitz M., M.D., Horch R. E., M.D. and Beier J.P., M.D.*

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Department of Plastic and Hand Surgery, University Hospital of Erlangen, FriedrichAlexander-University of Erlangen-Nürnberg (FAU), Erlangen, Germany Head: Univ.-Prof. Dr. med. Dr. h.c. R. E. Horch, M.D.

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*Corresponding author

Dept. of Plastic and Hand Surgery

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Prof. Dr. med. Justus P. Beier, M.D.

Head: Univ.-Prof. Dr. med. Dr. h. c. R. E. Horch University Hospital of Erlangen Krankenhausstr. 12 91054 Erlangen

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Germany Phone: +49-9131-8533277 Fax: +49-9131-8539327

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Financial support: none

ACCEPTED MANUSCRIPT Summary Scalp reconstruction is a challenging task for the reconstructive surgeon. In consideration of the anatomical and cosmetic characteristics, the defect depth and size, an armamentarium of reconstructive procedures ranging from skin grafts over local flaps to free tissue transfer has

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been described. In this 10-year retrospective study, 85 operative procedures for scalp

reconstruction were performed at our department. The underlying entity, defect size/depth, reconstructive procedure, complications, and mean hospital stay were analyzed. In most

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cases, scalp reconstruction was necessary after oncologic resection (67%) or radiation therapy (16%). A total of 85 operative procedures were performed for scalp reconstruction including

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local flaps (n=50), free tissue transfer (n=18), and skin grafts (n=17). Regarding the complication rate, we could detect an overall major complication rate of 16.5% with one free flap loss. Briefly, local flaps are an adequate and safe procedure for limited scalp defects. In the case of extensive scalp defects affecting the calvarium, prior multiple surgical

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interventions and/or radiation, we prefer free tissue transfer.

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Key words: scalp reconstruction, free tissue transfer, microsurgery, composite scalp defects

ACCEPTED MANUSCRIPT INTRODUCTION Reconstruction of scalp defects after oncologic resection, and after radiation therapy in particular, is a challenging task for the reconstructive surgeon. Composite defects affecting the cranium, sometimes with concomitant cerebrospinal leakage, often demand an

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interdisciplinary approach with the neurosurgery service. Considering the three-dimensional aspect of the calvarium, the limited expandability of scalp tissue and the cosmetic aspect of the hair-bearing region, as well as the demand for sufficient coverage of the cranial cavity in

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the case of full-thickness cranial composite defects, a broad spectrum of reconstructive techniques is required. For this purpose, manifold reconstructive procedures have been

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described, namely skin grafts, local flaps, and free tissue transfer (Mehrara et al. 2006; Wang et al. 2007).

Considering superficial scalp defects with remaining periosteum, skin grafting and/or local flaps are an appropriate reconstructive procedure. Even extensive scalp defects affecting the

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periosteum and/or calvarium can be covered with local flaps (Desai et al. 2015). Because of the low donor site morbidity rate, the possibility to replace like with like and a consequently appealing esthetic appearance, local flaps should be considered as the superior

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reconstructive method for most scalp defects.

Extensive composite defects, including the calvarium and the soft tissue after infection,

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radiation therapy, or prior surgery, often limit the use of local flaps because of compromised vascularization and free tissue transfer remains as the only solution for safe and long-lasting defect reconstruction (Desai et al. 2015). Despite the promising achievements in the field of tissue engineering, these cases still require free tissue transfer for an appropriate reconstruction (Horch et al. 2014; Roux et al. 2015). This retrospective study aims to investigate the complications and outcome of a series of 85 consecutive scalp reconstructions. In particular, we tried to figure out the specific conditions of the reconstructive procedures concerning the underlying entities, defect size and depth, as

ACCEPTED MANUSCRIPT well as hospitalization and their effect on final outcome, including minor and major complication rates.

MATERIALS AND METHODS

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A retrospective analysis of 77 patients, who underwent scalp reconstruction with a total of 85 operative procedures during a 10-year period from 2004–2014, was performed on the basis of complete medical records review, including follow-up outpatient cause in 47% of the cases

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(mean 19.5 weeks, range 1–229 weeks). Most of the patients were male (64.7%) and the mean age was 60.1 years. Indications for scalp reconstruction were malignancy (67%) followed by

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radiation therapy (16%), trauma (7%), alopecia, and wound healing disorder after prior surgery (5%) (Fig. 1). Malignancy consisted of melanoma (33%), squamous cell carcinoma (30%), basal cell carcinoma (11%), sarcoma (12%), and other rare entities in the remaining 14% (Table 1).

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The operative spectrum for scalp reconstruction included skin grafts, local flaps, and free tissue transfer. The analysis consisted of the defect size as well as localization, complications,

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and length of hospital stay. Major complications included flap loss, thrombosis, or hematoma requiring revision surgery. Minor complications (e.g. infection or wound healing disorder)

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were treated conservatively. Medical histories and comorbidities were also assessed. Concerning scalp reconstruction with local flaps, the need for skin grafting for donor site closure and, in the case of free tissue transfer, the choice of recipient vessels were evaluated. Statistical analysis was performed using IBM SPSS Statistics for Windows, version 22.0. (IBM SPSS, Armonk, NY, USA). First, data were analyzed for normal distribution using the Kolmogorov-Smirnov test. Kruskal-Wallis and Freeman-Halton tests were used as nonparametric tests, because the data were not normally distributed. P values ≤0.05 were defined as statistically significant differences among the treatment groups. P values ≤0.001

ACCEPTED MANUSCRIPT were considered as highly significant. Values are presented as mean arbitrary units ± standard deviation. RESULTS

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During the observation period, a total of 85 operations were performed in 77 patients. In most (80%) cases, the scalp defect was characterized by a full-thickness skin and soft tissue lesion without bony defect. The mean defect size was 41.3 cm² (range 0.8–235.6 cm²). The average

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overall hospital stay was 13.6 days and 10 days after the final operative procedure.

Concerning the overall hospital stay in dependence on the underlying entity for scalp

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reconstruction, we could detect a significantly longer hospital stay in patients with radiotherapy-related defects, as compared with alopecia and squamous cell carcinoma and the latter ones compared with melanoma (data not shown).

Most scalp defects (59%) could be reconstructed with local flaps followed by free tissue

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transfer (21%) and partial as well as full-thickness skin grafts (16% and 4%, respectively). Comparing the hospital stay after surgery and the underlying operative procedure, we could detect statistically significant differences between local flaps (with/without skin graft for

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donor site closure) and free tissue transfer (Fig. 2).

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Major complications during hospital stay were found in 9 cases, whereas minor complications occurred in one case. Regarding the operative procedure and the complication rate, we could not find a statistically significant difference among the different surgical procedures. After discharge from hospital, only 40 patients (47%) could be included for follow-up. In most cases (n=27), no complications were registered. Nine patients displayed complications, of which 5 required revision surgery due to unstable scar with tumor recurrence (n=1), wound healing disorders (n=3) or osteomyelitis (n=1). Nine patients required cosmetic corrective surgery as a result of scarring (n=4), dog ears (n=4), or flap thinning (n=1).

ACCEPTED MANUSCRIPT Skin grafts Seventeen skin grafts were performed for scalp reconstruction. The average defect size was 35.8 cm2 and the mean hospital stay after surgery was 6.4 days. The mean age was 51.7 years, and in most cases malignancies were the underlying reason for scalp reconstruction. Except

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one full-thickness skin graft failure, no complications were observed with a take rate of 100%. One patient underwent corrective surgery as a result of scarring alopecia in the follow-up

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period.

Local flaps

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A total of 50 reconstructions were performed with local flaps (Group A) or local flaps with additional skin grafting (Group B). The average defect size was 27.7 cm2 and the mean age 59.8 years. All patients displayed a full-thickness defect of the scalp, and in two cases the dura mater underwent reconstruction. In most cases, malignancy was the cause of the scalp

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defect. Twenty-five skin grafting procedures had to be performed for donor site closure in this group. In Group B, treated with local flaps and additional skin grafting, a statistically significant larger defect area than in group A (p ≤ 0.05) was observed. The mean defect size

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in Group A was 16.1 cm² (0.8–50.3 cm²) and in Group B was 39.2 cm² (4.0–84.8 cm²) (Fig. 3). Concerning the hospital stay after surgery, we could detect a statistically significant

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difference between Groups A and B (5.8 versus 9 days, p ≤ 0,001) (Fig. 2). Except for one partial flap necrosis, all local flaps survived, and four major and one minor complications resulted during the hospital stay. Major complications encompassed hematoma (n=2) and wound healing disorder (n=2). There was no statistical correlation between the localization of the defect and minor or major complications (p = 0.422 and 0.107, respectively). Six patients required dog-ear (n=4) or scar (n=2) correction.

Free tissue transfer

ACCEPTED MANUSCRIPT During the period from 2004–2014, a total of 18 free flaps were performed for scalp reconstruction, with most of the 14 flaps being performed during the second half of the observational period. All patients in this group presented with a full-thickness scalp defect with exposed and at least affected (4 patients) or even defects (14 patients) of the calvarium.

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The average defect size was 80.5 cm2. The mean age and hospital stay after surgery were 61.7 years and 20.9 days, respectively. In 50% of the patients requiring scalp reconstruction with free tissue transfer, radiation therapy (n=9) was the major reason, followed by malignancy

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(n=7) and wound healing disorder (n=2). The latissimus dorsi muscle flap was used in most cases (n=12), followed by rectus abdominis flap (n=4), antero lateral thigh (n=1), and radial

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forearm flap (n=1). The recipient vessels were identified preoperatively by computed tomography angiography (n=13). In the other cases, the recipient vessels were evaluated by digital subtraction angiography. The recipient vessels used for anastomosis were as follows: superficial temporal artery (n=8), superficial thyroid artery (n=3), lingual artery (n=2) (all

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end-to-end), and external carotid artery (n=5) (end-to-side). Since 2009, venous anastomosis was performed using the ring-pin coupler device (Synovis Micro Companies Alliance, Birmingham, AL, USA).

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No minor complications but four major complications including arterial thrombosis (n=2), venous stasis and hematoma (n=1) were observed during the hospital stay. There was one flap

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loss that resulted from arterial thrombosis, whereas the two other flaps were salvaged. One flap (latissimus dorsi flap) was successfully re-anastomosed to a different terminal branch of the external carotid artery, the other one (radial forearm flap) by using an interpositional vein graft to hook up the flap’s cephalic vein to the internal jugular vein (instead of the superficial temporal vein). Subsequently, nine patients presented for secondary correction procedures including removal of the monitoring island (n=7), scar correction (n=1) and flap thinning (n=1).

ACCEPTED MANUSCRIPT DISCUSSION During 2004–2014, a total of 85 operative procedures were performed for scalp reconstruction including skin grafts (n=17), local flaps (n=50) and free tissue transfer (n=18). In our patient series, we could detect an overall major complication rate of 16.5%. Our results

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are consistent with the pertinent literature, reporting complication rates ranging from 11 up to 59% (Hussussian and Reece 2002; Newman et al. 2004; Kruse-Losler et al. 2006; Mehrara et al. 2006; Labow et al. 2009; Khan et al. 2010; Shonka et al. 2011; Chao et al. 2012).

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In contrary to the results of Janus et al., we could observe a statistically significant correlation between the reconstructive procedure and the complication rate (Janus et al. 2015). In the

major complications (p ≤ 0.05).

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present study, the patient cohort treated with free flaps displayed statistic significant more

The overall hospital stay was 13.6 days and after scalp reconstruction patients stayed for 10 days in the hospital. Comparing the different reconstructive procedures, we found a

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statistically significant difference between local flaps (with or without skin grafting) and free tissue transfer (p ≤ 0.001), with the latter one involving a significantly longer hospital stay (Fig. 2). These results are not surprising when considering that free tissue transfer was mostly

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conducted mostly in patients with large composite scalp defects as a consequence of complex

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wounds requiring a more intensive postoperative care. Skin grafting represents a safe and simple option for scalp reconstruction only if sufficient, well-vascularized tissue covering the cranial bone is preserved; however, it eventually results in a less esthetic reconstructive outcome, as the skin grafts not only are hairless but also display a significantly different skin coloring as compared with the surrounding skin of the scalp. Intact periosteum is the prerequisite for successful skin grafting. If no suitable vascular bed is present, an attempt can be made to promote the formation of granulation tissue. Methods vary, from drilling holes in the lamina externa to the removal of the outer lamina with the use of a chisel. The necessary time frame until sufficient granulation tissue is

ACCEPTED MANUSCRIPT available ranges between 6 and 8 weeks (Molnar et al. 2000; Koenen et al. 2008; Barry et al. 2009). In contrast, Muhlstadt et al. reported on the possibility of milling the tabula externa with a rose head burr and subsequent skin grafting. After 1 week, the take-up rate was 100% (Muhlstadt et al. 2012). However, these measures usually do not result in a long-term stability

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to render them the first choice. To prevent involuntary extradural hematoma, preoperative computed tomography is useful to determine the thickness of the calvarium prior to the drilling procedure.

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In particular, patients with severe comorbidity or a palliative situation can profit from skin grafting as the reconstructive procedure, as this represents a less invasive procedure and can

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result in shortened hospitalization. However, the use of skin grafts is limited because of poor cosmetic appearance. Furthermore, radiation therapy and defects including those in the calvarium or dura mater are not suitable for skin grafting (Mehrara et al. 2006). The average defect size in our cohort for split thickness skin graft was 43.9 cm2 (4.9–235.6

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cm2) and for full thickness skin grafts 46.9 cm2 (11.8–94.2 cm2). Other than one graft failure, no complications occurred. Another promising approach for elderly patients with multiple comorbidities is the use of dermal regeneration templates in combination with split skin grafts

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(e. g. Integra®, Integra LifeSciences Corporation, Plainsboro, NJ, USA). Thus wound closure with Integra® can be achieved either by secondary intention within 3 weeks or delayed split-

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thickness skin grafting with shorter surgery and hospitalization duration (De Angelis et al. 2015; Schiavon et al. 2016). Local flaps are considered as the most feasible procedure for stable closure of scalp defects less than 150 cm2 (Newman et al. 2004; Mehrara et al. 2006). In our own patient collective, the average defect size was 27.7 cm2 (0.8–84.8 cm2). Reasons for choosing local flaps are the availability of well-vascularized and hair-bearing tissue for coverage of full-thickness complex wounds due to radiation therapy or infection. Furthermore, devascularized bone after craniotomy and cerebrospinal fluid leakage can be faced with local flaps (Newman et al.

ACCEPTED MANUSCRIPT 2004; Mehrara et al. 2006). In case of cerebrospinal fluid leakage, the dura should always be sealed prior to reconstruction, in particular when using local flaps to prevent recurrent cerebrospinal fluid leakage and subsequent revision surgery. Indications for scalp reconstruction with local flaps in our study included alopecia (n=4),

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substantial bone loss (n=8), and complex wounds after radiation therapy (n=8), for instance. The larger the defect for reconstruction, the higher the likelihood for split-thickness skin

grafting to become necessary for donor side closure. In our cohort, those patients treated with

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local flaps and additional split thickness skin grafting (Group B) presented with an average defect size that was significantly larger than the defect size in the cohort without skin grafting

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(Group A) (p ≤ 0.05). The defect size in Group A ranged from 0.8 to 50.3 cm² (mean 16.1 cm²), whereas the defect size in Group B ranged from 4.0 to 84.8 cm² (mean 39.2 cm²). The overall complication rate was 24%, including 7 major and 5 minor complications. Soft tissue expanders are an important tool to generate larger local flaps. In our study, we did not

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perform tissue expansion prior to defect reconstruction with local flaps, as most scalp defects were a result of tumor resection or radiation with exposed calvarium requiring immediate reconstruction. We furthermore do not recommend tissue expansion of radiated and/or

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infected scalp tissue because of the compromised vascularization and possible healing disorder. However, tissue expansion is a good indication for scar correction of hair-bearing

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scalp, generating larger local flaps without the need for donor side closure with split thickness skin. Although other authors suggest a primary closure of wounds smaller than 3 cm2, we performed scalp reconstruction with local flaps if the underlying defect was a result of radiation therapy or infection (Fowler and Futran 2014) even if the size of the defect would possibly allow for primary closure under significant tension. Scalp defects larger than 50–200 cm2 caused by radical tumor resection or radiation therapy require free tissue transfer for sufficient reconstruction (Beasley et al. 2004; Kruse-Losler et al. 2006; Janus et al. 2015).

ACCEPTED MANUSCRIPT In our own patient collective, the defect size ranged from 23.6 to 176.7 cm2 (mean 80.5 cm2). Compared with local flaps, free tissue transfer was used for larger defects (p ≤ 0.001) including the calvarium (14/18) and/or dura mater (n=2). In most cases, radiation therapy (n=9) and radical tumor resection (n=7) have been responsible for free tissue transfer.

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Because of its long constant pedicle and large dimension, the latissimus dorsi flap is a

favorable option for scalp reconstruction (Lipa and Butler 2004; Newman et al. 2004; Wang et al. 2007; Shonka et al. 2011; Chao et al. 2012; Goertz et al. 2015; Janus et al. 2015). The

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latissimus dorsi can also be used as a myo-osseocutaneous free flap in combination with a rib and/or the scapula for skull reconstruction (Lee et al. 2013). In 12 cases, we used solely the

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latissimus dorsi flap as a myocutaneous or muscle flap, with additional skin grafting. Mostly the latissimus dorsi flap was used for scalp defects based on radiation therapy to cover the cranium with well-vascularized tissue. It is known that myocutaneous flaps provide high vascularized tissue, which is the fundamental basis for wound healing and infection cure in

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general, and the latissimus dorsi flap enables reconstruction of such extended defects in particular. In addition, the rectus abdominis flap, the anterolateral thigh flap, the radial forearm flap, and the greater omentum flap are recommended for scalp reconstruction

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(Losken et al. 2002; Shen and Shen 2003; Calikapan et al. 2006; Sweeny et al. 2012). In our own patient collective, we used the rectus abdominis flap in four cases and the antero-

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lateral thigh and radial forearm flap in two cases. The greater omentum as a free flap was not used because of the significant donor site complications. Hultman et al. reported 18.5% donor site complications, such as abdominal wall infection, symptomatic hernia, and postoperative ileus (Hultman et al. 2002). In our patient cohort, we preoperatively performed computed tomography angiography or digital subtraction angiography to identify the prospective recipient vessels and to exclude potential vessel aberration. In accordance with the corresponding literature, we used primarily (44%) the superficial temporal vessels for microsurgical anastomosis (Beasley et al. 2004;

ACCEPTED MANUSCRIPT Mehrara et al. 2006; Oh et al. 2011; Chao et al. 2012; Herrera et al. 2012; Eck et al. 2014; Doscher et al. 2015; Goertz et al. 2015). The superficial temporal vessels were dissected in the preauricular area adjacent to the defect. In the case of using the superficial thyroid artery, lingual artery, and external carotid artery, dissection started at the carotid triangle, and

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preparation ended at the proximal defect border. We did not perform tunneling of the skin in order to prevent compression of the vascular pedicle. We preferred the superficial temporal vessels due to their reliable course, easy access, and proximity to the defect. However, if the

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caliber or blood flow appeared not to be sufficient, lingual artery and external carotid artery represented a safe alternative option. Since 2009, we have used a ring-pin coupler device for

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venous anastomosis whenever possible (n = 12 of 13), which had been demonstrated to increase the safety of venous anastomosis and to shorten flap ischemia (Rozen et al. 2010; Ardehali et al. 2014).

Concerning the success rate of free tissue transfer, our data reveal a flap survival of 94%,

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which is comparable with data in the current literature (Newman et al. 2004; Wang et al. 2007; Chang et al. 2010; Herrera et al. 2012; Fischer et al. 2013). Most patients in the current study who required free tissue transfer for scalp reconstruction

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displayed composite defects as a result of craniectomy, and soft tissue damage as a result of infection, cerebrospinal fluid leakage, and or radiation therapy. Despite the fact that patients

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can develop a “neurological susceptibility to a skull defect” (also known as “syndrome of the sinking skin flap” or “syndrome of the trephined” after craniectomy), we did not perform cranioplasty with autogenous bone or alloplastic material (Sedney et al. 2015; Honeybul et al. 2016). Considering the specific medical history, we considered wound healing disorder after prior surgery and or radiation therapy as well as chronic infected wounds as strong contraindications for cranioplasty. Furthermore, most defects affecting the calvarium were located above the hat brim line (n=13). We and our neurosurgery service believe that calvarial

ACCEPTED MANUSCRIPT defects above the hat brim line do not necessarily require bony reconstruction for brain protection. From our point of view, cranioplasty with its putative benefits including prevention of the “syndrome of the trephined,” improved calvarial contour and bony protection does not justify

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the high associated complication rate (Afifi et al. 2010; Lee et al. 2013; Broughton et al. 2014; Reddy et al. 2014; Zanaty et al. 2015).

The mean age in our patient collective was 61.7 years (range 46–81 years) and differed only

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marginally from the mean age of the patients requiring local flaps (59.8 years; range 2–88 years). If a rigorous assessment prior to surgery (including the patient’s comorbidities and

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constitution) is performed, we regard free tissue transfer as a safe procedure even in the elderly population (Ferrari et al. 2013; Grammatica et al. 2015; Klein et al. 2016; Simunovic et al. 2016).

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CONCLUSIONS

In summary, local flaps are a suitable and safe procedure for limited scalp defects. In the case of large scalp defects affecting the calvarium, prior multiple surgical interventions, and/or

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radiation therapy, free tissue transplantation represents the favorite reconstructive method, which can be applied with low complication rates even in an older patient population, if the

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necessary routine in microsurgical procedures is warranted.

Conflict of interest

The authors confirm that there is no conflict of interest.

Acknowledgements The present work is part of Anja Hubertus doctoral thesis for obtaining the degree “Dr. med.” This research did not receive any specific grant from funding agencies in the public,

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commercial, or not-for-profit sectors.

ACCEPTED MANUSCRIPT REFERENCES

Afifi, A., R. S. Djohan, W. Hammert, F. A. Papay, A. E. Barnett and J. E. Zins (2010). Lessons learned reconstructing complex scalp defects using free flaps and a

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cranioplasty in one stage. J Craniofac Surg 21(4): 1205-1209.

Ardehali, B., A. N. Morritt and A. Jain (2014). Systematic review: anastomotic microvascular device. J Plast Reconstr Aesthet Surg 67(6): 752-755.

SC

Barry, R. B., J. A. Langtry and C. M. Lawrence (2009). The role of cortical bone fenestration

Dermatol 160(5): 1110-1112.

M AN U

in the management of Mohs surgical scalp wounds devoid of periosteum. Br J

Beasley, N. J., R. W. Gilbert, P. J. Gullane, D. H. Brown, J. C. Irish and P. C. Neligan (2004). Scalp and forehead reconstruction using free revascularized tissue transfer. Arch Facial Plast Surg 6(1): 16-20.

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Broughton, E., L. Pobereskin and P. C. Whitfield (2014). Seven years of cranioplasty in a regional neurosurgical centre. Br J Neurosurg 28(1): 34-39. Calikapan, G. T., S. Yildirim and T. Akoz (2006). One-stage reconstruction of large scalp

EP

defects: anterolateral thigh flap. Microsurgery 26(3): 155-159. Chang, K. P., C. H. Lai, C. H. Chang, C. L. Lin, C. S. Lai and S. D. Lin (2010). Free flap

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options for reconstruction of complicated scalp and calvarial defects: report of a series

of cases and literature review. Microsurgery 30(1): 13-18.

Chao, A. H., P. Yu, R. J. Skoracki, F. Demonte and M. M. Hanasono (2012). Microsurgical reconstruction of composite scalp and calvarial defects in patients with cancer: a 10year experience. Head Neck 34(12): 1759-1764. De Angelis, B., P. Gentile, E. Tati, D. J. Bottini, I. Bocchini, F. Orlandi, G. Pepe, C. Di Segni, G. Cervelli and V. Cervelli (2015). One-stage reconstruction of scalp after full-

ACCEPTED MANUSCRIPT thickness oncologic defects using a dermal regeneration template (Integra). Biomed Res Int 2015: 698385. Desai, S. C., J. P. Sand, J. D. Sharon, G. Branham and B. Nussenbaum (2015). Scalp reconstruction: an algorithmic approach and systematic review. JAMA Facial Plast

RI PT

Surg 17(1): 56-66.

Doscher, M., A. H. Charafeddine, B. A. Schiff, T. Miller, R. V. Smith, O. Tepper and E. S. Garfein (2015). Superficial temporal artery and vein as recipient vessels for scalp and

SC

facial reconstruction: radiographic support for underused vessels. J Reconstruct Microsurg 31(4): 249-253.

M AN U

Eck, D. L., S. L. Koonce, B. M. Al Majed and G. Perdikis (2014). Evaluation of options for large scalp defect reconstruction: a 12-year experience. Eplasty 14: e10. Ferrari, S., C. Copelli, B. Bianchi, A. Ferri, T. Poli, T. Ferri and E. Sesenna (2013). Free flaps in elderly patients: outcomes and complications in head and neck reconstruction after

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oncological resection. J Craniomaxillofac Surg 41(2): 167-171. Fischer, J. P., B. Sieber, J. A. Nelson, S. J. Kovach, J. A. Taylor, J. M. Serletti, L. C. Wu, S. Kanchwala, S. P. Bartlett and D. W. Low (2013). A 15-year experience of complex

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scalp reconstruction using free tissue transfer-analysis of risk factors for complications. J Reconstruct Microsurg 29(2): 89-97.

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Fowler, N. M. and N. D. Futran (2014). Achievements in scalp reconstruction. Curr Opin Otolaryngol Head Neck Surg 22(2): 127-130.

Goertz, O., L. von der Lohe, R. Martinez-Olivera, A. Daigeler, K. Harati, T. Hirsch, M. Lehnhardt and J. Kolbenschlag (2015). Microsurgical reconstruction of extensive oncological scalp defects. Front Surg 2: 44. Grammatica, A., C. Piazza, A. Paderno, V. Taglietti, A. Marengoni and P. Nicolai (2015). Free flaps in head and neck reconstruction after oncologic surgery: expected outcomes in the elderly. Otolaryngol Head Neck Surg 152(5): 796-802.

ACCEPTED MANUSCRIPT Herrera, F., R. Buntic, D. Brooks, G. Buncke and A. K. Antony (2012). Microvascular approach to scalp replantation and reconstruction: a thirty-six year experience. Microsurgery 32(8): 591-597. Honeybul, S., C. Janzen, K. Kruger and K. M. Ho (2016). The incidence of neurologic

RI PT

susceptibility to a skull defect. World Neurosurg 86: 147-152.

Horch, R. E., J. P. Beier, U. Kneser and A. Arkudas (2014). Successful human long-term application of in situ bone tissue engineering. J Cell Mol Med 18(7): 1478-1485.

SC

Hultman, C. S., G. W. Carlson, A. Losken, G. Jones, J. Culbertson, G. Mackay, J. Bostwick, 3rd and M. J. Jurkiewicz (2002). Utility of the omentum in the reconstruction of

M AN U

complex extraperitoneal wounds and defects: donor-site complications in 135 patients from 1975 to 2000. Ann Surg 235(6): 782-795.

Hussussian, C. J. and G. P. Reece (2002). Microsurgical scalp reconstruction in the patient with cancer. Plast Reconstruct Surg 109(6): 1828-1834.

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Janus, J. R., B. W. Peck, N. M. Tombers, D. L. Price and E. J. Moore (2015). Complications After Oncologic Scalp Reconstruction: A 139-Patient Series and Treatment Algorithm. Laryngoscope 125(3): 582-588.

EP

Khan, M. A. A., S. N. Ali, M. Farid, M. Pancholi, S. Rayatt and L. H. Yap (2010). Use of Dermal Regeneration Template (Integra) for Reconstruction of Full-Thickness

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Complex Oncologic Scalp Defects. J Craniofac Surg 21(3): 905-909.

Klein, H. J., N. Fuchs, T. Mehra, R. Schweizer, T. Giesen, M. Calcagni, G. F. Huber, P. Giovanoli and J. A. Plock (2016). Extending the limits of reconstructive microsurgery

in elderly patients. J Plast Reconstr Aesthet Surg. Koenen, W., S. Goerdt and J. Faulhaber (2008). Removal of the outer table of the skull for reconstruction of full-thickness scalp defects with a dermal regeneration template. Dermatol Surg 34(3): 357-363.

ACCEPTED MANUSCRIPT Kruse-Losler, B., D. Presser, U. Meyer, C. Schul, T. Luger and U. Joos (2006). Reconstruction of large defects on the scalp and forehead as an interdisciplinary challenge: experience in the management of 39 cases. EJSO 32(9): 1006-1014. Labow, B. I., H. Rosen, S. A. Pap and J. Upton (2009). Microsurgical reconstruction: a more

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conservative method of managing large scalp defects? J Reconstruct Microsurg 25(8): 465-474.

Lee, J. C., G. M. Kleiber, A. T. Pelletier, R. R. Reid and L. J. Gottlieb (2013). Autologous

Plast Reconstruct Surg 132(4): 967-975.

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immediate cranioplasty with vascularized bone in high-risk composite cranial defects.

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Lee, L., J. Ker, B. L. Quah, N. Chou, D. Choy and T. T. Yeo (2013). A retrospective analysis and review of an institution's experience with the complications of cranioplasty. Br J Neurosurg 27(5): 629-635.

Lipa, J. E. and C. E. Butler (2004). Enhancing the outcome of free latissimus dorsi muscle

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flap reconstruction of scalp defects. Head Neck 26(1): 46-53. Losken, A., G. W. Carlson, J. H. Culbertson, C. Scott Hultman, A. V. Kumar, G. E. Jones, J. Bostwick, 3rd and M. J. Jurkiewicz (2002). Omental free flap reconstruction in

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complex head and neck deformities. Head Neck 24(4): 326-331. Mehrara, B. J., J. J. Disa and A. Pusic (2006). Scalp reconstruction. J Surg Oncol 94(6): 504-

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508.

Molnar, J. A., A. J. DeFranzo and M. W. Marks (2000). Single-stage approach to skin grafting the exposed skull. Plast Reconstruct Surg 105(1): 174-177.

Muhlstadt, M., C. Thome and C. Kunte (2012). Rapid wound healing of scalp wounds devoid of periosteum with milling of the outer table and split-thickness skin grafting. Br J Dermatol 167(2): 343-347. Newman, M. I., M. M. Hanasono, J. J. Disa, P. G. Cordeiro and B. J. Mehrara (2004). Scalp reconstruction: a 15-year experience. Ann Plast Surg 52(5): 501-506; discussion 506.

ACCEPTED MANUSCRIPT Oh, S. J., J. Lee, J. Cha, M. K. Jeon, S. H. Koh and C. H. Chung (2011). Free-flap reconstruction of the scalp: donor selection and outcome. J Craniofac Surg 22(3): 974977. Reddy, S., S. Khalifian, J. M. Flores, J. Bellamy, P. N. Manson, E. D. Rodriguez and A. H.

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Dorafshar (2014). Clinical outcomes in cranioplasty: risk factors and choice of reconstructive material. Plast Reconstruct Surg 133(4): 864-873.

Roux, B. M., M. H. Cheng and E. M. Brey (2015). Engineering clinically relevant volumes of

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vascularized bone. J Cell Mol Med 19(5): 903-914.

Rozen, W. M., I. S. Whitaker and R. Acosta (2010). Venous coupler for free-flap

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anastomosis: outcomes of 1,000 cases. Anticancer Res 30(4): 1293-1294. Schiavon, M., M. Francescon, D. Drigo, G. Salloum, R. Baraziol, J. Tesei, E. Fraccalanza and F. Barbone (2016). The Use of Integra Dermal Regeneration Template Versus Flaps for Reconstruction of Full-Thickness Scalp Defects Involving the Calvaria: A Cost-

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Benefit Analysis. Aesthetic Plast Surg.

Sedney, C. L., W. Dillen and T. Julien (2015). Clinical spectrum and radiographic features of the syndrome of the trephined. J Neurosci Rural Pract 6(3): 438-441.

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Shen, Y. M. and Z. Y. Shen (2003). Greater omentum in reconstruction of refractory wounds. Chin J Traumatol 6(2): 81-85.

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Shonka, D. C., A. E. Potash, M. J. Jameson and G. F. Funk (2011). Successful Reconstruction of Scalp and Skull Defects: Lessons Learned from a Large Series. Laryngoscope

121(11): 2305-2312.

Simunovic, F., S. U. Eisenhardt, V. Penna, J. R. Thiele, G. B. Stark and H. Bannasch (2016). Microsurgical reconstruction of oncological scalp defects in the elderly. J Plast Reconstr Aesthet Surg.

ACCEPTED MANUSCRIPT Sweeny, L., B. Eby, J. S. Magnuson, W. R. Carroll and E. L. Rosenthal (2012). Reconstruction of scalp defects with the radial forearm free flap. Head Neck Oncol 4: 21. Wang, H. T., D. Erdmann, K. C. Olbrich, A. H. Friedman, L. S. Levin and M. R. Zenn

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(2007). Free flap reconstruction of the scalp and calvaria of major neurosurgical

resections in cancer patients: lessons learned closing large, difficult wounds of the dura and skull. Plast Reconstruct Surg 119(3): 865-872.

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Zanaty, M., N. Chalouhi, R. M. Starke, S. W. Clark, C. D. Bovenzi, M. Saigh, E. Schwartz, E. S. Kunkel, A. S. Efthimiadis-Budike, P. Jabbour, R. Dalyai, R. H. Rosenwasser and S.

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I. Tjoumakaris (2015). Complications following cranioplasty: incidence and predictors

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in 348 cases. J Neurosurg 123(1): 182-188.

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Figure 1. Indications for scalp reconstruction: malignancy (67%), radiation therapy (16%),

cases, tumor resection required scalp reconstruction.

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trauma (7%), alopecia (5%), and wound healing disorder after prior surgery (5%). In most

Figure 2. Hospitalization after surgery in days according to local flaps without (A) or with

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units ± standard deviation. ***P ≤ 0.001.

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(B) additional skin grafting and free tissue transfer (C). Data are shown as mean arbitrary

Figure 3. Correlation between defect size and the selected procedure. Scalp defects were reconstructed with local flaps (A), local flaps and additional skin grafting (B), or free tissue transfer (C). Data are shown as mean arbitrary units ± standard deviation. *P ≤ 0.05; ***p ≤

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0.001.

ACCEPTED MANUSCRIPT Entity

n

Age (y)

Melanoma SCC BCC Sarcoma Bowen disease Adenocarcino ma Nevus

19 17 6 7 2 2 2

Skin grafting 2 6 1 2 — —

Local flap 17 8 5 4 2 —

Free flap — 3 — 1 — 2

Hospitalization (days) 6.6 9.6 7.3 7.7 7.5 85

26.5

6.1

1

1

—

4.5

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Table 1. Treated malignancy in our patient collective

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56 77.8 64.8 81.3 76 61

Defect size (cm2) 38.7 31.6 19.2 41.2 18.5 131.5

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Note: SCC, squamous cell carcinoma; BCC, basal cell carcinoma. Hospitalization indicates

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hospital stay after surgery.

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ACCEPTED MANUSCRIPT

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5% 5%

EP AC C

16%

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7%

67%

Malignancy Radiation therapy Trauma Alopecia Wound healing disorder

Hospital stay after surgery (days) 5

0

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25

20

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15

10

EP

45

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40

35

30

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50

***

A B

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ACCEPTED MANUSCRIPT

***

***

C

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ACCEPTED MANUSCRIPT

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180

***

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160

120

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100 80

*

EP

60 40 20 0

***

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Defect area (cm2)

140

A

B

C