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Scalp Reconstruction: a 15-Year Experience

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Scalp Reconstruction: a 15-Year Experience ORIGINAL ARTICLE Scalp Reconstruction: A 15-Year Experience Martin I. Newman, MD,† Matthew M. Hanasono, MD,† Joseph J. Disa, MD,* Peter G. Cordeiro, MD,* and Babak J. Mehrara, MD* grafts, or hardware. Although numerous case series and Abstract: Scalp reconstruction after ablative surgery can be chal- lenging. A useful reconstructive algorithm is lacking. The purpose reports have been published, study populations have been low of this study was to evaluate the authors’ experience and to identify and a useful reconstructive algorithm has not been offered. an appropriate reconstructive strategy. This was a retrospective The purpose of this study was (1) to evaluate our long-term review of all patients treated by the authors’ service for scalp defects experience with scalp reconstructions in a large series of during a 15-year period. Reconstructive methods, independent fac- cancer patients, (2) to identify an appropriate algorithm for tors, and outcomes were analyzed. A total of 73 procedures were scalp reconstruction in the cancer population, and (3) to performed in 64 patients. Techniques for reconstruction included identify comorbid factors that increased the rates of compli- primary closure, grafts, and local and distal flaps. A correlation cations in this patient population. between reconstructive technique and complications could not be demonstrated. However, an increased incidence of complications was correlated with a history of radiation, chemotherapy, cerebro- spinal fluid leaks, and an anterior location of the ablative defect (P METHODS Ͻ 0.05). Important tenets for successful management of scalp This was a retrospective review of all scalp reconstruc- defects are durable coverage, adequate debridement, preservation of tions performed at Memorial Sloan–Kettering Cancer Center blood supply, and proper wound drainage. Local scalp flaps with during a 15-year period ending November 2002. Patients who skin grafts, and free tissue transfer remain the mainstay of recon- underwent scalp reconstruction were identified by query of struction in most instances. our prospectively maintained electronic medical record data- Key Words: scalp, reconstruction, flap, skin graft, microsurgery base. Charts identified were examined with attention to the (Ann Plast Surg 2004;52: 501–506) following details: patient demographics; past medical and surgical history; nature of primary scalp or intracranial dis- ease; size, location, and nature of scalp defect; presence or absence of CSF leakage; method of reconstruction; adjunc- overage of scalp defects after ablative surgery can be tive therapies; and type and nature of complications. Cchallenging. Reconstructions may be especially difficult Complications were recorded and divided into 2 cate- in patients who have been treated with external beam radia- gories: major and minor. Major complications included death, tion or when repair is performed after wound breakdown or events requiring return to the operating room, or postopera- infection. Previous scars or fibrosis may preclude the use of tive illnesses requiring intensive medical intervention. Minor adjacent tissue for local rotational flaps. Often, cerebrospinal complications were primarily wound-related issues that were fluid (CSF) leaks are present and are further complicated by managed successfully with conservative therapy. the presence of allograft material, nonvascularized bone Complications were examined as a function of recon- structive method and comorbid factors, including diabetes, Received December 16, 2003. Accepted for publication December 17, 2003. steroids, tobacco use, prior scalp surgery, ablative defect From *The Plastic and Reconstructive Service, Memorial Sloan–Kettering more than 100 cm2, anterior location of defect, craniotomy, Cancer Center, New York, NY, and †The Division of Plastic Surgery, CSF leak, CSF drain, chemotherapy, and preoperative radia- Cornell University Medical Center, New York, NY. Presented at the 20th annual meeting of the Northeastern Society of Plastic tion therapy. Univariate analysis was performed using the Surgeons; Baltimore, MD, October 2–4, 2003. Pearson bivariate correlation coefficient with P Յ 0.05 con- Reprints: Babak J. Mehrara, MD, 1275 York Avenue, Room C-1189, New sidered significant. Logistic regression analysis was per- York, NY 10021. Tel: (212) 639–8639, Fax: (212) 717–3677, E-mail: formed to determine the independent contribution of risk [email protected] factors to postoperative complication. Multiple linear regres- Copyright © 2004 by Lippincott Williams & Wilkins ISSN: 0148-7043/04/5205-0501 sion analysis was performed to evaluate the combined effects DOI: 10.1097/01.sap.0000123346.58418.e6 of variables examined on postoperative complications. Annals of Plastic Surgery • Volume 52, Number 5, May 2004 501 Newman et al Annals of Plastic Surgery • Volume 52, Number 5, May 2004 RESULTS TABLE 2. Ablative and Reconstructive Procedures Seventy-three procedures were performed in 64 pa- tients. Demographics and frequency of independent factors Variable n % identified are summarized (Table 1). Indication for ablative Indications for ablation procedure, location of resultant scalp defect, and method of Skin cancers 50 68.5 closure are presented (Table 2). Sarcomas 10 13.7 No intraoperative complications were noted. A total of Primary CNS neoplasms 8 11.0 17 postoperative complications were identified after 17 inde- Metastases 4 5.5 pendent procedures (Table 3). There were 7 major postoper- Defects ative complications, which included 1 perioperative death in Average defect size, cm2 104.8 SD Ϯ 112.3 a free flap patient who died 15 days postoperatively second- Defect size range, cm2 0–540 ary to pneumonia and renal failure. Other major complica- Location of defects tions included 1 hematoma, 1 wound dehiscence after a Frontal/frontoparietal 22 30.0 primary closure, 1 wound dehiscence after a local flap clo- Occipital/posterior 6 8.2 sure, 1 free flap distal necrosis, 1 complete free flap loss, and Parietal 11 15.1 1 “systemic” complication not otherwise specified. There Postauricular 1 1.4 were 12 minor complications and all were managed conser- Posterior 1 1.4 vatively. They included 6 partial skin graft losses or delayed Temporal/temporoparietal 18 24.7 healing, 4 wound infections or dehiscences, 1 hematoma, and Vertex 7 9.6 1 tissue expander leak that required exchange in the office Unspecified 7 9.6 suite. Methods of closure Complications examined as a function of reconstructive Primary closure 3 4.1 method identified postoperative complications in 2 of the 3 Skin graft 13 17.8 primary repairs (66.7%), 2 of the 13 skin grafts (15.4%), 7 of Local flap 29 39.7 the 29 local flaps (24.1%), and 8 of the free flaps (28.6%; Fig. Free flap 28 38.4 1). There was no statistically significant correlation between CNS, central nervous system. TABLE 1. Patient Demographics Variable n % TABLE 3. Complications Complication n % Study population No. of patients 64 Major complication 7 9.6 No. of procedures 73 Perioperative death (pneumonia) 1 1.4 Demographics Hematoma 1 1.4 Male 36 56.3 Dehiscence 2 2.7 Female 28 43.8 Distal flap necrosis 1 1.4 Average age, y 58.8 SD Ϯ 19.8 Flap loss 1 1.4 Age range, y 9–93 Systemic complication, NOS 1 1.4 Independent patient factors Minor 12 16.4 Diabetes 5 6.8 Partial STSG loss/delayed 6 8.2 Steroid use 15 22.4 Infection/dehiscence 4 5.5 Tobacco history 10 15.9 Hematoma 1 1.4 Prior Scalp surgery 43 65.2 Tissue expander leak 1 1.4 2 Scalp defect Ͼ 100 cm 26 38.2 Overall 19 26.0 Anterior location of defect 40 60.6 NOS, not otherwise specified; STSG, split-thickness skin graft. Craniotomy 24 36.4 CSF leak 5 7.6 CSF drain 6 9.1 Chemotherapy 11 15.3 reconstructive technique and major, minor, or overall com- Preoperative XRT 32 43.8 plication rate. Specific to choice of free flap, 16 rectus abdominis muscle transfers resulted in 3 total complications CSF, cerebrospinal fluid; XRT, radiation therapy. (18.8%), 1 major and 2 minor. Eleven latissimus dorsi flaps 502 © 2004 Lippincott Williams & Wilkins Annals of Plastic Surgery • Volume 52, Number 5, May 2004 Scalp Reconstruction FIGURE 1. Postoperative complications as a function of reconstructive technique. Major and minor complications are plotted for each type of closure used in our study. Note the lack of statistical significance between groups. resulted in 4 total complications (36.4%), 2 major and 2 lation was noted between preoperative scalp radiation, neo- minor complications. One radial forearm flap was performed adjuvant or postoperative chemotherapy, CSF leak, and in this series and was without complication. anterior location of the ablative defect (P Յ 0.05; Table 4). Complications were also examined as a function of Preoperative scalp radiation correlated with an increase in the patient demographics (age and gender), class of malignancy, overall complication rate, (17.1% vs. 37.5%, P ϭ 0.05) as did and independent risk factors using univariate analysis (Pear- chemotherapy (19.7% vs. 54.5%, P ϭ 0.01). The presence of son correlation coefficient). A statistically significant corre- a CSF leak correlated with an increase in major complications TABLE 4. Univariate and Multivariate Statistical Analysis of Independent Variables and Postoperative Complications Univariate Analysis*, P Value Multivariate Analysis†, P Value Independent Major Minor Total Major Minor Total Variable Complications Complications Complications Complications Complications Complications Diabetes 0.38 0.91 0.51 0.97 0.85 0.54 Steroids 0.50 0.81 0.52 0.96 0.91 0.60 Tobacco 0.61 0.43 0.67 0.98 0.86 0.14 Prior scalp surgery 0.33 0.90 0.46 0.99 0.57 0.81 Defect Ͼ 100 cm2 0.54 0.79 0.53 0.96 0.30 0.55 Anterior location 0.04 0.26 0.02 0.94 0.30 0.08 Craniotomy 0.47 0.37 0.75 0.98 0.83 0.11 CSF leak 0.01 0.91 0.09 0.97 0.91 0.84 CSF drain 0.50 0.92 0.73 0.99 0.84 0.86 Chemotherapy 0.03 0.23 0.01 0.97 0.89 0.08 Radiation 0.12 0.27 0.05 1.00 0.60 0.20 *Pearson bivariate correlation.
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