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Scalp and Skull Reconstruction in Patients Irradiated for Tinea Capitis in Childhood: the Scalp Exchange Procedure

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Scalp and Skull Reconstruction in Patients Irradiated for Tinea Capitis in Childhood: the Scalp Exchange Procedure Published online: 2020-09-06 THIEME Original Article e61 Scalp and Skull Reconstruction in Patients Irradiated for Tinea Capitis in Childhood: The Scalp Exchange Procedure Ehud Fliss, MD1 Arik Zaretski, MD1 Eyal D. Maoz-Halevy, MD2 Eyal Gur, MD1 Ravit Yanko, MD1 1 Department of Plastic and Reconstructive Surgery, The Microsurgery Address for correspondence Ravit Yanko, MD, Department of Plastic Unit, Tel-Aviv Sourasky Medical Center, Affiliated with the Sackler and Reconstructive Surgery, Tel-Aviv Sourasky Medical Center, Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel 6 Weizman Street, Tel-Aviv 6423906, Israel 2 Department of Neurology, Sheba Medical Center affiliated with the (e-mail: [email protected]). Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel J Reconstr Microsurg Open 2020;5:e61–e68. Abstract Background Approximately 70,000 Israelis underwent scalp irradiation for tinea capitis infection during their childhood, as did many other children worldwide. Long-term follow-up data showed that these children had an increased risk of aggressive and multiple nonmelanoma skin cancers, meningiomas, and other malig- nancies. Resection of these lesions creates a defect of soft tissue, bone, and dura, and requires scalp and skull reconstruction with local or free flaps in the irradiated field. Methods Sixteen patients with a history of childhood scalp irradiation underwent scalp and skull reconstruction in our department (2000–2018). Data on demographics, oncological status, operative details, and postoperative outcome were retrospectively collected and analyzed. Results The study group included 11 males and 5 females (average age at surgery, 70 years). The most common lesions were meningiomas (n ¼ 9) and basal cell carcinomas (n ¼ 8), and the most common indication for reconstruction was chronic exposure of deep structures (skull, dura, brain tissue, and titanium mesh; n ¼ 9). Thirteen patients underwent primary free flap reconstruction and three underwent primary local flap reconstruction. Flap failure requiring reoperation occurred in one patient of the free flap reconstruction group (7%) and in all three patients of the local flap reconstruction group. Conclusion Long-term consequences of childhood depilatory treatments of the scalp Keywords by irradiation are now surfacing. Our experience showed that in such cases, surgeons ► microsurgery should aim for a more aggressive approach with wide resection and primary free flap ► scalp reconstruction reconstruction, and that favorable long-term functional and aesthetic results can safely ► scalp irradiation be achieved using this reconstruction approach. – Between the 1930s and 1950s, X-ray epilation was widely used 9.5), and other malignancies.3 7 These sequelae are becoming worldwide as primary treatment for tinea capitis (TC) infec- increasingly apparent in the past two decades due to the tion.1,2 In Israel, approximately 70,000 people were treated latency period of these pathologies.1 Typically, the nature of during their childhood. The reported long-term consequences the skin tumors and meningiomas in this patient population is of this treatment include increased risk for nonmelanoma skin more aggressive than in the general population, and there may cancers (NMSC; relative risk [RR], 3.6–4.9), meningiomas (RR, be a greater tendency of recurrence or development of received DOI https://doi.org/ Copyright © 2020 by Thieme Medical February 26, 2020 10.1055/s-0040-1716418. Publishers, Inc., 333 Seventh Avenue, accepted after revision ISSN 2377-0813. New York, NY 10001, USA. July 9, 2020 Tel: +1(212) 760-0888. e62 Scalp Exchange Post–Tinea Capitis Irradiation Fliss et al. multiple primary lesions.6,7 Due to the poor skin quality and Table 1 Patients and preoperative characteristics impairment of wound healing that follows radiation, many sustain local complications such as wound dehiscence and n (%) Mean Range infection. Moreover, patients undergoing craniectomy or Total 16 (100) craniotomy are left with extruding foreign material through Male gender 11 (68) chronic wounds and require additional procedures in many Age at surgery (y) 70 59–90 cases.8 Several aspects of the sequelae of childhood scalp irradia- Lesion tion have been studied, such as the type and prevalence of Meningioma 9 (56) nonmelanoma skin cancers (NMSC) and meningioma appear- – Basal cell carcinoma 8 (50) ance the genetic typing.1 3,9,10 However, to the best of our Osteoradionecrosis 4 (25) knowledge, complex scalp and/or skull reconstruction in this and radiodermatitis population have not been reported before. The purpose of this Squamous cell carcinoma 2 (12) article is to present our experience in the reconstruction of scalp and skull defects in patients with a history of childhood Myxofibrosarcoma 1 (6) X-ray epilation for TC. Multiple lesions 5 (31) Defect surface area (cm2)a 70.5 14.2–139 Methods Prior treatment All consecutive patients with a history of childhood radiation Radiation 9 (56) for TC infection, who required and underwent complex scalp Craniotomy/craniectomy 8 (50) and skull reconstructive surgery at our institution between Cranioplasty 2 (12) 2000 and 2018, were retrospectively analyzed. Following Skull burring 2 (12) approval of the ethical institutional review board, their medical charts were reviewed, and the following data were Local 5 FU 1 (6) retrieved: patient demographics (age, sex, etiology, and Indication for scalp comorbidities) and flap characteristics (defect and flap and/or skull reconstruction components and recipient vessels). Their postoperative Chronic sinus/foreign 9 (56) course and complications were recorded throughout the material exposure length of the follow-up period (at least 6 months). Intracranial tumor 3 (18) Minor complications were defined as those requiring only involving skin conservative or medical interventions during hospital stay. Large skin tumor 2 (12) Major complications were defined as those that required Unknown 2 (12) management with reoperation within 30 days or that resulted in admission to the intensive care unit or demise. aMissing for four patients. Results neous sinus or exposure of deep structures (skull, dura, brain tissue, and titanium mesh) that was sustained by nine Patient and Lesion Characteristics patients. Intracranial tumor involving the skin was the A total of 16 patients with a history of childhood radiation indication in additional three patients and a rare sarcoma therapy required complex scalp and skull reconstruction (fibromyxosarcoma) in one patient. during the study period. The majority of patients were males (n ¼ 11), and the average age at surgery was 70 years (range, Surgery 59–90 years; ►Table 1). The lesions included multiple and Sixteen free tissue transfers were performed in 14 patients. A atypical meningioma (nine patients), recurrent basal cell free flap was performed as the primary mode of reconstruction carcinoma (BCC; eight patients), osteoradionecrosis (ORN) in 13 patients, and an additional three were performed as and radiodermatitis (four patients), squamous cell carcino- salvage procedures for failed reconstruction (►Table 2). The ma (SCC, two patients), and myxofibrosarcoma (one patient). most common method of reconstruction was a free latissimus Five patients had a combination of tumors, consisting of dorsi (LD) flap with or without a fascia lata graft and split- meningioma and BCC. The size of the defect ranged from thickness skin graft (STSG; n ¼ 10). The superficial temporal 5.7 cm  2.5 cm and up to 10.3 cm Â13.5 cm with a mean vessels were the most common recipient vessels when a free surface area of 70.5 cm2. Nine patients underwent additional flapwas used(n ¼ 13)withno need for veingrafts. Anastomosis irradiation as adjunctive treatment for the current patholo- to the superficial temporal vessels was performed at the level of gy. Eight patients had undergone a previous craniotomy the tragus, or slightly more proximal, without disrupting the and/or craniectomy with titanium mesh insertion, and three parotid gland. Local flaps were used as primary mode of of them underwent repeated resections due to recurrence of reconstruction in three patients. These three patients under- meningioma. The most common indication for scalp and/or went a total of seven surgeries (six repeated local flaps and one skull resection and reconstruction was a chronic osteocuta- free flap) due to partial or complete lap failure. Journal of Reconstructive Microsurgery Open Vol. 5 No. 2/2020 Scalp Exchange Post–Tinea Capitis Irradiation Fliss et al. e63 Table 2 Clinical and operative course Pt Age (y) Lesion Defect Defect Primary Primary Secondary Free Recipient size (cm) local free reconstruction flap vessels flap flap 001 65 Multiple Scalp, calvaria 9.5  6.5 þÀ LD ST meningiomas and BCC 002 59 Multiple Scalp, calvaria Missing þÀ LD ST meningiomas and BCC 003 68 Multiple BCC Scalp, calvaria 12  9 þÀ LD ST 004 69 ORN Scalp, calvaria, 6.5  5 þLocal flap X 2 À NA dura, brain 005 67 Multiple BCC Scalp, calvaria Missing þÀ LD ST 006 90 Multiple BCC Scalp, calvaria, 12  9.5 þÀ LD F dura, brain 007 61 Multiple Scalp, calvaria, 6.5  3 þÀ RA ST meningiomas dura 008 63 SCC Scalp, calvaria 14  9 þÀ LD ST 009 77 BCC and SCC Scalp, calvaria 10  5 þÀ LD ST 010 67 Multiple Scalp, calvaria 8.5  5.5 þLocal flap À NA meningiomas and BCC 011 69 Atypical Scalp, calvaria, Missing þFree flap LD ! ALT ST þ ST meningioma dura 012 64 Multiple Scalp, calvaria, 8  4.6 þÀ TDAP ST meningiomas dura and BCC 013 71 Recurrent Scalp, calvaria, 8.5  5.5 þÀ ALT F meningioma dura 014 70 Recurrent Scalp, calvaria, 5.7  2.5 þÀ ALT F meningioma dura 015 73 Fibromyxosarcoma Scalp, calvaria, 10.3  13.5 þÀ LD ST dura 016 78 Atypical Scalp, calvaria Missing þLocal flap ! ALT! LD ST þ ST meningioma Free flap X 2 Abbreviations: ALT, anterolateral thigh; BCC, basal cell carcinoma; F, facialvessels;LD,latissimusdorsi;NA,notapplicable;ORN,osteoradionecrosis; RA, rectus abdominis; SCC, squamous cell carcinoma; ST, superficial temporal vessels; TDAP, thoracodorsal artery perforator.
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