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REPAIR OPTIONS: SCALP
SCALP DEFECTS WITH EXPOSED BONE
Rotation options are preferred
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Due to the scalp anatomy, there are limited reconstructive options when closing defects on the scalp.1 Side-to-side closure is the primary option for small defects. Second intention healing often leaves pleasing cosmetic results, particularly on hairless skin. Flaps are useful for medium- to large-sized defects and are preferred over grafts especially if defects are missing periosteum. Advancement and rotation flaps are useful in defects on hair-bearing skin although rotation flaps are ideal over the curved surfaces of the scalp. Full-thickness skin grafts can be used but require a vascular bed for survival. In large and deep defects, split-thickness grafts may provide the only feasible option.
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Combination closures, such as transposition flaps combined with split-thickness grafts or partial side-to-side closure with second intention healing or skin grafting, can also be useful on the scalp to repair larger defects. Tissue expansion and free tissue transfers allow reconstructive surgeons to reconstruct even nearly total scalp defects.
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May not be possible if scalp is too tight; wide undermining under the galea often affords only small amounts of extra movement
Broad and atrophic scars can occur if the galea is not correctly approximated
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Test for scalp laxity by pinching the skin or by sliding the skin backwards and forwards over the bone. Unfortunately, this technique to assess scalp laxity may be misleading. For this reason, it is a good idea to have a ‘plan B’ in case there is less skin movement than anticipated for the planned repair.
If laxity is considered adequate, draw an ellipse around the defect oriented perpendicular to the direction of greatest skin laxity. This often runs anterior to posterior.
Incise the ellipse, ensuring the angle of the scalpel is parallel to the hair follicles. Extirpate the ellipse. Undermine in the subgaleal plane.