Closure of Scalp and Forehead Defects Using External Tissue Expander

ORIGINAL ARTICLE Closure of Scalp and Forehead Defects Using External Tissue Expander

Ashley G. O’Reilly, MD; William R. Schmitt, MD; Randall K. Roenigk, MD; Eric J. Moore, MD; Daniel L. Price, MD

Objective: To describe the novel use of an external tis- achieved in 5 patients. One patient required bilateral ad- sue expander in the reconstruction of scalp and fore- vancement rotation flaps, and 1 patient healed by second head defects. intention. One patient with a history of scalp irradiation and diabetes had partial skin loss after device removal and Methods: A prospective review was performed on 7 pa- required reconstruction with a latissimus dorsi myocuta- tients who underwent extirpation of head and neck ma- neous free flap. There were no other postoperative com- lignant neoplasms resulting in scalp and forehead de- plications, wound breakdown, or device failures. fects. Reconstruction was performed using an external tissue expander device. Patient clinical factors, defect size, Conclusion: External tissue expansion is a safe and ef- and photographs were collected. fective technique for closing large scalp and forehead defects that would otherwise require skin grafting or free Results: Seven patients had large scalp and forehead de- flap reconstruction. fects ranging in greatest dimension from 5.0ϫ4.0 to 8.0ϫ7.0 cm. The external tissue expander was in place Arch Facial Plast Surg. 2012;14(6):419-422. for 6 to 14 days, reducing the defect sizes by 50% to 99%. Published online September 3, 2012. At the time of device removal, primary closure was doi:10.1001/archfacial.2012.662

HE SCALP AND FOREHEAD and forehead reconstruction using a novel are challenging areas in external tissue expander (DermaClose RC; which to achieve optimal Wound Care Technologies). closure, both technically and cosmetically. The poor METHODS flexibilityT and limited appropriate donor tissue make even small defects difficult to close. As in all areas of the head and neck, Our prospective case series includes patients it is ideal for repairing tissue defects with who were treated for head and neck cancer at tissue that is similar in color, thickness, Mayo Clinic, Rochester, Minnesota, from Au- and texture. The hair-bearing nature of the gust 2010 to October 2011. Each patient un- scalp makes this goal challenging to derwent wound closure with the novel exter- achieve. nal tissue expansion device. After institutional Several options exist for closure of me- review board approval, data were gathered using the institutional electronic records. Data re- dium and large scalp and forehead de- garding patient clinical factors, defect size, and fects, ranging from skin grafts and granu- photographs were collected. After the malig- lation via second intention to more nant neoplasm was removed and negative mar- extensive advancement flaps and micro- gins were confirmed, an external tissue expan- vascular free tissue transfers. Many of these sion device was applied. The patients were seen options fail to achieve the goal of replac- in the clinic every 48 to 72 hours for wound ing the defects with like tissue, often re- examination and advancement of the tension sulting in poor cosmesis. Tissue expan- device when required. sion has previously been a reliable method The external tissue expander is a device that for achieving closure of scalp defects but accelerates wound closure by applying a continuous tension to wound edges until the skin Author Affiliations: Divisions has the disadvantages of delaying defini- Author Affil of Otorhinolaryngology has sufficiently stretched to allow primary clo- of Otorhinol (Drs O’Reilly, Schmitt, Moore, tive treatment and preplanning. We sug- sure or to result in a much smaller wound O’Reilly, Sch and Price) and Dermatology gest exploring the use of a novel external (Figure 1). Application of the external de- Price) and D (Dr Roenigk), Mayo Clinic, tissue expander for closure of scalp and vice involves placement of 316L surgical stain- Roenigk), M Rochester, Minnesota. forehead defects. We report 7 cases of scalp less steel skin anchors approximately 1 to 3 cm Rochester, M

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©2012 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/02/2021 flap was required to reconstruct the defect and was performed without complication. Two patients had dehis- cence of their wounds after primary closure. After device removal, these patients had their wounds closed in a 1-layer fashion with staples. Both wounds dehisced 1 to 2 weeks after staple removal. The remaining patients underwent a 2-layer closure with a polydioxanone suture followed by a polypropylene suture (Prolene; Ethi- con Inc). There were no incidences of wound breakdown with this method of closure.

Figure 1. External continuous tissue expander (DermaClose RC; Wound Care COMMENT Technologies).

Defects of the scalp and forehead create substantial recon- structive challenges. The skin in these areas has limited elasticity, and the hair-bearing nature of the scalp makes adequate cosmesis difficult to achieve. Several options exist for closure of medium and large scalp and forehead defects. Primary closure is optimal but is seldom achieved for defects that are larger than 3 cm in diameter. Wide undermining of the scalp in a subgaleal plane will usually be required and provides only limited additional closure.1 Figure 2. Intraoperative application of external tissue expander (DermaClose RC; Wound Care Technologies) to a scalp defect measuring 9.5ϫ5.0 cm. Healing by second intention offers an additional option for defects with periosteum present. It allows optimal tu- from the wound edge and 2 to 3 cm apart from each other. An- mor surveillance and avoids complex reconstruction pro- 2 chors are stabilized with 2 standard wide (6-7 mm) skin staples. cedures. Disadvantages include the time and compli- The USP 2 monofilament nylon line housed in the device’s ten- ance that are required for proper wound care as well as a sion controller is then attached around each anchor in a shoe- poor cosmetic result. The prolonged wound care may in- lace or radial fashion. Finally, tension is applied around the skin terfere with timely postoperative radiation therapy, and anchors by turning the knob of the tension device until the con- irradiation may compromise the final result, leaving the troller is fully tightened, indicated by an audible clutch mecha- patient with exposed bone. The area will not contain hair, nism (Figure 2). For wounds longer than 10 cm or wider than and the scar may be atrophic and have prominent telan- 5 cm, multiple devices may be used in series. giectasis that may be unsightly.3 Skin grafts may be used over any size of defect. Heal- RESULTS ing is facilitated by an intact periosteum; however, expos- ing the diploic space of bone or galeal rotation flaps will The mean patient age for this 7-patient case series was allow healing of skin grafts over exposed bone. Similar to 70 years (age range, 57-87 years). After extirpation of the healing by second intention, split-thickness skin grafts will malignant neoplasms with the patient under general or often be compromised after irradiation. Also, poor cos- local anesthesia, the defects ranged from 5.0ϫ4.0 to mesis and lack of hair-bearing skin are the main disad- 8.0ϫ7.0 cm in greatest dimension. The device was placed vantages of using skin grafts. Various local and advance- intraoperatively and remained in place for 6 to 14 days. ment flaps are commonly used for medium to large scalp The patients required tightening of the device 1 to 3 times defects. Because of the scalp’s inelasticity, they will typi- between device placement and removal. The tightening cally need to be proportionally larger than other facial flaps.4 was performed during outpatient office visits. After re- Distant pedicled flaps, including the latissimus dorsi and moval of the device, the defects decreased in size by 50% lower trapezius flaps, have also been used for occipital and to 99% (Table). Five patients were able to achieve pri- lateral scalp defects.5 They have limited reach and cannot mary closure at the time of device removal. One patient extend above the temporal line. Microvascular tissue trans- required bilateral advancement rotation flaps, and 1 pa- fer is often required for reconstruction of large defects, par- tient healed by second intention once the device was re- ticularly in cases with cranial defects. Microvascular skin moved. Defects before and after device placement, with flaps are reliable options that allow coverage of large de- resultant closure for 4 patients, are shown in Figure 3. fects with vascular tissue in a single-stage procedure.6 The The patients tolerated the device being in place. Tight- main disadvantages are the poor tissue match and lack of ening of the device caused moderate pain, which was con- hair-bearing skin, length of the procedure, and morbid- trolled with a combination of oral analgesics and a local ity to donor sites. anesthetic. There were no cases of wound breakdown at The use of tissue expanders for scalp reconstruction the sites of the skin anchors. One patient had partial skin has become increasingly popular over the last 2 de- loss after device application and bilateral advancement cades. Two main types have been described in the scalp: rotation flaps. He had poorly controlled diabetes and a long-term tissue expansion using Silastic balloons under 6.0 ϫ 7.5-cm vertex scalp defect that had been previ- the galea and intraoperative sustained external tissue ex- ously irradiated. A latissimus dorsi myocutaneous free pansion.7 Both techniques allow reconstruction of scalp

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©2012 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/02/2021 Table. Characteristics of Scalp and Forehead Defects Reconstructed With an External Tissue Expander

Patient No./ Initial Defect Length of Device Final Defect % Wound Sex/Age, y Pathologic Findings Size, cm Application, d Size, cm Closure Final Closure Technique 1/M/77 Scalp vertex defect: 6.0 ϫ 7.5 8 2.5 ϫ 9.0 50.0 Bilateral advancement failed STSG for rotation flaps leiomyosarcoma 2/F/83 Scalp vertex defect: 7.5 ϫ 7.5 6 1.3 ϫ 2.0 96.0 Primary closure melanoma 3/M/66 Scalp vertex defect: 9.5 ϫ 5.0 8 0.2 ϫ 2.0 99.2 Primary closure leiomyosarcoma 4/M/86 Right parietal defect: 6.5 ϫ 7.5 14 3.5 ϫ 2.5 82.0 Second intention metastatic urolethial cancer 5/F/57 Scalp vertex defect: 8.0 ϫ 7.0 7 0.2 ϫ 0.2 99.9 Primary closure recurrent basal cell carcinoma 6/M/57 Paramedian forehead defect: 9.0 ϫ 5.0 8 1.4 ϫ 1.5 95.4 Primary closure reconstruction for nasal basal cell carcinoma 7/F/57 Scalp vertex: melanoma 5.0 ϫ 4.0 6 1.0 ϫ 1.0 95.0 Primary closure

Abbreviation: STSG, split-thickness skin graft.

Patient 2 Patient 3 Patient 6 Patient 7

Defect size 7.5 × 7.5 cm 9.5 × 5.0 cm 9.0 × 5.0 cm 5.0 × 4.0 cm

Before surgery

6 d 8 d 8 d 6 d After surgery

6 wk 3 wk 10 wk Follow-up

Figure 3. Defects before and after external tissue expander placement with resultant closure for 4 patients.

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©2012 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/02/2021 defects with matched tissue—in color, thickness, and tex- the application requires closure of the defect at a later time. ture.8 However, the process of tissue expansion using Si- The advantages include the ability to apply the device with lastic balloons is typically prolonged and requires the ex- the patient under local anesthesia in cases in which the pansion process to be planned and executed before the patient would not tolerate a general anesthetic, the lack wound is created. It prohibits the use of tissue expansion of prolonged inpatient hospitalization, and the absence of in acute wounds due to trauma or in cases of malignant donor site morbidity that occurs with free flap reconstruc- transformation requiring timely resection. tion. This device offers an alternative option for large scalp The scalp is an ideal location for external tissue expan- and forehead defects that would not be amenable to pri- sion. Cox et al9 reported on the use of an external closure- mary closure and would otherwise require skin grafting assisted device applied intraoperatively at the time of re- or free flap reconstruction. section of a large scalp sebaceous nevus. This device was applied to a 2-cm defect for a period of time in the oper- ating room, reducing the defect size to allow primary clo- Accepted for Publication: April 23, 2012. sure. Chaouat et al2 described a case in which both skin Published Online: September 3, 2012. doi:10.1001 expansion with inflatable expanders and an external tis- /archfacial.2012.662 sue expander were used to close a scalp defect due to Correspondence: Ashley G. O’Reilly, MD, Division of Oto- trauma. Two inflatable expanders were inserted under each rhinolaryngology, Mayo Clinic, 200 First St SW, Roch- side of the defect, and the external tissue expander was ester, MN 55905 ([email protected]). then applied to the skin edges. Over the course of 30 days, Author Contributions: Study concept and design: O’Reilly, the prosthesis was inflated and the external tissue ex- Moore, and Price. Acquisition of data: O’Reilly, Schmitt, pander was tightened to bring the wound edges closer. The and Roenigk, Analysis and interpretation of data: O’Reilly, defect was ultimately closed with a local rotation flap. Roenigk, and Price. Drafting of the manuscript: O’Reilly External tissue expansion uses the principles of me- and Roenigk. Critical revision of the manuscript for im- chanical creep and stress relaxation to reduce the size of portant intellectual content:O’Reilly, Schmitt, Moore, and large defects. Mechanical creep is the stretching of a ma- Price. Administrative, technical, and material support: terial, in this situation skin, under a constant load over O’Reilly and Schmitt. Study supervision: Moore and Price. time. When skin is stretched, its convoluted collagen fi- Financial Disclosure: None reported. bers straighten and realign parallel to each other. Elon- Previous Presentation: This study was presented as a gation of these fibers beyond the inherent extensibility poster at the American Academy of Otolaryngology– of skin results in mechanical creep. Displacement of wa- Head and Neck Surgery Annual Meeting; September 11- ter from the collagen network and microfragmentation 14, 2011; San Francisco, California. of elastic fibers makes the skin more viscous, allowing it to stretch. Stress relaxation is defined as the decrease in REFERENCES retractive forces exhibited by a material when it is held at a given stretch over time.10 Tissue expansion, presu- 1. Hoffman JF. Management of scalp defects. Otolaryngol Clin North Am. 2001;34 turing, undermining, and skin retraction rely on these (3):571-582. 2. Chaouat M, Lalanne B, Levan P, Mimoun M. Skin expansion and external tissue principles to assist with wound closure. extension techniques in the treatment of a traumatic scalp defect. Scand J Plast In conclusion, we describe a novel external tissue ex- Reconstr Surg Hand Surg. 2002;36(1):50-52. pansion device that can be applied intraoperatively at the 3. Fosko SW, Branham GH. Reconstruction issues after Mohs surgery. Facial Plast time the defect is created and achieves closure in a rela- Surg Clin North Am. 1998;6(3):379-385. 4. Ahuja RB. Geometric considerations in the design of rotation flaps in the scalp tively short time. After device removal, wounds should be and forehead region. Plast Reconstr Surg. 1988;81(6):900-906. closed in a 2-layer fashion to prevent delayed wound de- 5. Frodel JL Jr, Ahlstrom K. Reconstruction of complex scalp defects: the “Banana hiscence. This device appears to be appropriate for most Peel” revisited. Arch Facial Plast Surg. 2004;6(1):54-60. patient populations. We had one instance of a device- 6. Lutz BS, Wei FC, Chen HC, Lin CH, Wei CY. Reconstruction of scalp defects with induced tissue loss in a patient with diabetes who had re- free flaps in 30 cases. Br J Plast Surg. 1998;51(3):186-190. 7. Konior RJ, Kridel RWH. Tissue expansion in scalp surgery. Facial Plast Surg Clin ceived previous external beam irradiation. Caution should North Am. 1994;2(2):203. be exercised in patients in whom local tissue vascularity 8. Bauer BS, Few JW, Chavez CD, Galiano RD. The role of tissue expansion in the may be compromised. Although the device applies a con- management of large congenital pigmented nevi of the forehead in the pediatric stant tension, in our experience this required advance- patient. Plast Reconstr Surg. 2001;107(3):668-675. 9. Cox AJ III, Wang TD, Cook TA. Closure of a scalp defect. Arch Facial Plast Surg. ment every 48 to 72 hours, resulting in frequent office vis- 1999;1(3):212-215. its. Other disadvantages are that there is some discomfort 10. Wilhelmi BJ, Blackwell SJ, Mancoll JS, Phillips LG. Creep vs. stretch: a review of for patients during and after the device tightening and that the viscoelastic properties of skin. Ann Plast Surg. 1998;41(2):215-219.

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