1Department of Otolaryngology Head and Neck Surgery, Loyola University Medical Center, Maywood, IL 60153, USA.
2Department of Otolaryngology Head and Neck Surgery, Loyola University Chicago Stritch School of Medicine, Maywood, IL 60153, USA.
Correspondence to: Assoc. Prof. Amy L. Pittman, Department of Otolaryngology Head and Neck Surgery, Facial Plastics and Reconstructive Surgery, Microvascular, Loyola University Medical Center, 2160 S 1st Ave, Maywood, IL 60153, USA.
© The Author(s) 2021. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, sharing, adaptation, distribution and reproduction in any medium or format, for any purpose, even commercially, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.
Aim: Describe our institutional experience with different forms of reconstruction, including free tissue transfer vs. other newer techniques such as Integra, an artificial dermis composed of bovine collagen lattice with a layer of an artificial synthetic silicon epidermis.
Methods: We performed a retrospective review of patients who underwent full-thickness scalp reconstruction at a single tertiary care institution between January 2016 and March 2021. Patient demographic information, co-morbidities, defect depth and size, reconstruction type, American Society of Anesthesiologists (ASA) score, and postoperative complications were collected.
Results: Of the total 32 patients collected, 68.7% were male and 31.2% were female with an average age of 57.88 years (range 3-91 years). Malignancy (n = 26, 81.2%) was the most common reason for scalp reconstruction, followed by trauma (n = 5, 12.5%) and non-healing wound/exposed hardware (n = 2, 6.2%). The majority of patients underwent reconstruction with Integra +/- split thickness skin graft (n = 15, 46.8%) followed by tissue expander in combination with local flap (n = 6, 18.7%) and microvascular reconstruction (n = 5, 15.6%). Patients who underwent reconstruction with Integra had more medical comorbidities and a higher ASA score (2.93 ± 0.25) than those who underwent free tissue transfer (2.75 ± 0.96). Large defects (> 6.1 cm) were mostly reconstructed via the Integra/Integra + STSG method (n = 13, 59.1%), and all immunosuppressed patients were reconstructed with Integra (n = 3, 100%). Scalp defects with exposed dura were all reconstructed with free tissue transfer (n = 3, 100%). Four Integra-reconstructed patients required revision surgery due to partial graft failure.
Conclusion: Free tissue transfer is widely used to reconstruct large and full-thickness scalp defects. However, Integra can be a viable option in patients with numerous medical comorbidities or extensive scalp defects requiring complex reconstruction.
Free tissue transfer, full-thickness scalp defects, Integra, scalp malignancy
Acquired scalp defects can be a result of trauma, burns, tumor resection, chronic non-healing wounds, or radiation necrosis. Defects can vary in size and depth. It can involve hair-bearing and non-hair-bearing skin. Reconstruction is often challenging due to the complex anatomy of the scalp.
Scalp thickness ranges from 8 to 13 mm, often thicker in patients with advanced age, males over females, and increasing levels of body mass index (BMI)[1,2]. The layers of the scalp have been well described in previous literature and remembered by the mnemonic “SCALP”: S - skin, C - connective tissue, A - aponeurotic layer, L - loose connective tissue, and P - periosteum[3-5].
The skin covering the scalp often contains hair follicles and numerous sebaceous glands. The connective tissue layer is where the dense vascular supply of the scalp is located, resulting in the richest blood supply of any area of the skin in the body. Branches of the internal and external carotid arteries contribute, including the supraorbital and supratrochlear vessels (internal carotid artery) and the superficial temporal, posterior auricular, and occipital vessels (external carotid artery). The aponeurotic layer is also known as the galea and is the source of strength of the scalp. This thick connective tissue layer results in the scalp inelasticity and the convex shape of the skull, making closure with local flaps more difficult. Galeotomies or galeal scoring techniques can be used to relax and reduce tension during closure. In addition, the loose connective tissue accounts for the mobility of the scalp over the underlying skull. Lastly, the periosteum over the skull, also called the pericranium, is responsible for providing nutrition to the bone.
Reconstruction of scalp defects can range from nothing with healing by secondary intention, simple reconstruction such as primary closure, local rotational flaps or advancement flaps, skin grafting (partial vs. full-thickness), tissue expansion, to more complex procedures such as microvascular free tissue transfer.
The factors that may contribute to using free tissue transfer for scalp reconstruction include a large defect size, full-thickness scalp defect down to calvarium, full or partial thickness defects of the calvarium, previous treatments such as radiation, or patient-related factors[15,16]. The main goal of free tissue reconstruction is to cover the defect with vascularized soft tissue and limit donor site morbidity. Depending on patient age, co-morbidities, and defect size, certain reconstruction options may be a more suitable choice[17,18].
In recent decades, the Integra Dermal Regeneration Template® has been utilized as an option for the reconstruction of complex scalp defects, even with exposed calvarium. It is an artificial dermis composed of a bovine collagen/glycosaminoglycan polymer lattice covered by a thin synthetic silicone epidermis. This has provided an alternative to defects that otherwise would have been closed with free tissue transfer. Studies have shown similar outcomes in terms of the quality of closure technique and in relation to cost. In addition, Integra has the benefit of spared donor site morbidity, reduced operative time, and reduced inpatient stay compared to free tissue transfer, making it a viable option for patients who have significant comorbidities.
Microvascular techniques are certainly utilized in select scenarios at this academic center, a tertiary care referral center for complex cancer and trauma cases. The purpose of this paper was to evaluate the frequency of free tissue transfer vs. other techniques such as reconstruction with Integra for the closure of full-thickness defects of the scalp and associate common factors which led to the reconstructive choice.
After obtaining institutional review board approval, a retrospective review was conducted between January 2016 and March 2021. All patients who underwent full-thickness scalp reconstruction at a single tertiary care institution were identified. Information regarding patient demographic, medical co-morbidities, smoking history, prior chemotherapy or radiation history, pre-existing coagulopathy, defect etiology, size, depth, reconstruction type, postoperative complications, and any revision surgery were obtained. Patient’s calculated American Society of Anesthesiologist (ASA) classification score given by the anesthesia service at the time of surgery was also recorded to capture the patient’s risk of peri-operative morbidity and mortality.
Defect size was defined as small (< 3 cm), medium (3.1-6 cm), and large (> 6.1 cm). Defect depth was categorized as full-thickness defects of the scalp and partial or full-thickness defects of the calvarium with dura exposure. Reconstruction was categorized as either skin graft, Integra only, Integra followed by split-thickness skin graft (STSG), local flap, regional flap, tissue expander followed by local flap, or free tissue transfer. Postoperative complications were categorized as acute (occurring during a hospital stay) vs. subacute (occurring after a hospital stay). Acute complications were more related to free tissue transfer complications such as arterial or venous thrombosis, flap death, hematoma, infection, or revision surgery. Subacute complications included skin graft loss, Integra failure, flap necrosis, or infection.
A total of 32 patients with full-thickness scalp and/or partial or full-thickness calvarial defects were identified for qualitative data review. The average age was 57.88 years (range 3-91), with 22 males (68.7%) and 10 females (31.2%). All patients were of Caucasian ethnicity. Common medical co-morbidities included hypertension (n = 15, 46.8%), heart disease, (n = 6, 18.7%), diabetes mellitus (n = 6, 18.7%), chronic kidney disease (n = 4, 12.5%), obesity defined as BMI between 30 and 40 (n = 6, 18.7%), and severe obesity defined as BMI > 40 (n = 2, 6.25%). History of anticoagulation use prior to surgery was identified in 7 patients that underwent reconstruction (21.8%). Three patients (9.4%) were immunosuppressed at the time of treatment, and nine patients had a prior history of radiation therapy.
ASA scores calculated by Anesthesia at the time of surgery were averaged for Integra patients (2.93 ± 0.25) vs. free tissue patients (2.75 ± 0.96), see Figure 1. In addition, medical co-morbidities in Integra patients were compared against free tissue transfer patients in Figure 2.
Figure 1. Mean American Society of Anesthesiologist (ASA) classification scores (+/- SD) recorded at the time of surgery for patients with Integra reconstruction (n = 15) vs. free flap reconstruction (n = 4).
Figure 2. Comparing frequencies of medical co-morbidities among patients with Integra reconstruction vs. free tissue transfer. In this figure, all patients with DM2, kidney disease, obesity, severe obesity, immunosuppression, anticoagulation therapy, or prior chemotherapy underwent Integra reconstruction.
The majority of patients underwent reconstruction with Integra/ Integra + STSG (n = 15, 46.8%) followed by tissue expander with local flap reconstruction (n = 6, 18.7%). Free flap reconstruction was pursued in 5 patients (15.6%) with 2 latissimus dorsi flaps, 2 radial forearm free flaps, and 1 anterolateral thigh flap. STSG only or local flap reconstruction was completed in 3 patients each, respectively (9.4%). The most common reason for scalp reconstruction was malignancy (n = 26, 81.2%) followed by trauma (n = 4, 12.5%), and non-healing wound/exposed hardware (n = 2, 6.2%), see Figure 3.
The majority of the large defects (n = 22) were reconstructed via the Integra/ Integra + STSG method (59.1%). Breakdown of defect size and type of reconstruction can be seen in Figure 4.
Figure 4. Comparing frequencies of reconstruction type among defect sizes (small < 3 cm, medium 3.1-6 cm, large > 6.1 cm). Large defects were mostly reconstructed using Integra (n = 13, 59.1%).
Previously radiated patients were either reconstructed with free tissue transfer (n = 4, 12.5%) or Integra (n = 5, 15.6%). Immunosuppressed patients were all reconstructed with Integra (n = 3, 100%).
All exposed dura defects were reconstructed with free tissue transfer (n = 3, 100%). The majority of the partial bone defects with intact inner calvarium were reconstructed with Integra (n = 12, 63.1%), see Figure 5.
Four patients reconstructed with Integra were required to return to the operating room for revision surgery. Patient 1 had a persistent area of exposed bone and required coverage with more Integra. Patient 2 had a history of prior kidney transplant with poor wound healing and only had 60% Integra take, requiring another layer to be placed. Patient 3 developed a hematoma under the Integra, preventing any take of the graft. Finally, patient 4 had 85% take with a small area of exposed bone that developed while undergoing radiation treatment.
One patient reconstructed with a local flap required revision surgery due to distal necrosis. Integra was used for coverage of the defect. Patients reconstructed with local flaps, tissue expanders followed by local flaps, or free tissue transfer did not have any post-surgical complications.
Reconstruction of large and full-thickness scalp defects has been challenging. However, the advent of microvascular free tissue transfers in 1959 has greatly expanded the options and versatility of reconstruction. It provides consistently vascularized tissue and more robust soft tissue volume, especially important if postoperative radiation is pursued. Thus, it has been established as an efficacious method. Traditionally, the latissimus dorsi flap[23,24] has been the most commonly used, but the anterolateral thigh flap has also emerged in recent years as another frequently used flap[25-27]. The radial forearm flap, rectus abdominus flap, and free omentum covered by a skin graft are other described forms of reconstruction.
Some proponents for free tissue reconstruction of scalp defects argue that this may be the more conservative option given that other methods of reconstruction such as local flaps or STSG may result in the need for multiple procedures, prolonged wound care, and unsatisfactory aesthetic result. Numerous algorithms have been previously published in literature with recommendations on how to reconstruct large and/or full-thickness scalp defects. Prior literature has suggested free tissue transfer [Figure 6] with defects larger than 100 cm2 and previously irradiated scalps, defects > 100 cm2 wanting single stage reconstruction, size >
Figure 6. (A) Basosquamous carcinoma of the scalp with calvarium invasion. (B) Left frontoparietal craniotomy defect and dura resection with dura patched. (C) Latissimus dorsi free flap with skin graft placement without calvarial reconstruction. (D) Six weeks postoperative visit with a well healed wound.
Free tissue transfer is not without its risks of associated surgical complications such as flap failure and medical complications related to longer operative times and inpatient stays. Older age has been suggested as a possible risk factor for postoperative complications following microvascular procedures, but numerous studies have proven that age alone was not an independent risk factor[35-40]. Rather, frailty and patient co-morbidities may provide a more meaningful evaluation of an elderly patient’s candidacy for surgery and ability to tolerate general anesthesia. Frailty can be calculated using the Modified Frailty Index, with higher scores associated with higher complication rates and prolonged recovery[41,42]. In addition, ASA classification is an instrument with a proven predictive value toward complication rates and peri-operative morbidity and mortality. Thus, free tissue transfer is a viable option for reconstruction in patients who have been risked stratified by one of these many metrics.
Integra Dermal Regeneration Template® has recently emerged in the last few years as an option for scalp reconstruction, even for large and full-thickness defects. When there is absent pericranium and exposed calvarium, Integra allows for immediate closure of wounds without significant associated donor site morbidity. The outer table of the calvarium can be burred until there is bleeding bone, like what is typically performed prior to STSG placement. However, prior studies have shown that laying the Integra without any burring of the bone does not affect the percent take of the Integra[44-47]. The Integra is laid directly over the calvarium, and after a delayed period of time to allow for a layer of granulation tissue to form in the wound bed, a skin graft can be placed over but is not necessary [Figure 7]. Integra placement can be performed under sedation, limiting the morbidity with general anesthesia. Figure 1 compares ASA scores of patients who underwent standard of care with microvascular reconstruction vs. a newer method of reconstruction with Integra. It reveals that patients selected for Integra reconstruction often had elevated ASA scores. Although the results are not statistically significant, they demonstrate a selection bias toward pursuing Integra reconstruction in patients with an increased risk of complications with general anesthesia exposure. Integra has also played a role in reconstructing scalp defects following the excision of malignancy and previously has been demonstrated to be successful[48-50]. Overall, prior literature has supported the durability of Integra, reporting 95%-100% graft take even after adjuvant radiation therapy[50,51].
Figure 7. (A) Multiple full-thickness scalp defects after excision of squamous cell carcinoma. Underlying calvarium drilled until bleeding bone was exposed. (B) Three weeks after Integra graft placement. The wound demonstrates a bed of healthy granulation tissue. (C) Three months postoperative visit. The wound healed without skin graft placement.
Our institution recently implemented Integra use as a form of reconstruction during the past two years. A review of our patients revealed that an overwhelming majority of our large and full-thickness scalp defects were reconstructed using Integra. These subsets of patients were also found to have a higher ASA score or numerous medical co-morbidities that would increase the risk of postoperative complications with exposure to lengthy general anesthesia. We found success in the percentage of graft take and limited donor site morbidity, especially in patients that had poorer baseline functioning.
The four complications were due to failure for complete graft take with partial exposure of underlying bone. In all these cases, inconsistent and inadequate pressure was applied over certain areas of the Integra reconstruction, allowing serous or sanguineous fluid to collect between the wound bed and the graft [Figure 8]. Like any other skin graft, this prevents attachment and results in graft loss. In patients who required revision surgery due to inadequate Integra takes, usually, a wound vac was placed over the Integra to create a complete and consistent seal. We began implementing wound vac placement over large Integra reconstructions to prevent failure of graft take.
Figure 8. (A) Large full-thickness scalp defect after dermatofibrosarcoma excision reconstructed with Integra. Silicone sheet removal 3 weeks after Integra placement. (B) Area of exposed bone with incomplete coverage with granulation tissue. (C) Close examination of the area reveals neovascularization of the bone. (D) The second layer of Integra placed. (E) Three weeks after second Integra placement, wound bed covered with a meshed skin graft. (F) Four months post-reconstruction.
Integra was also noted to be useful for patients in whom hair-bearing reconstruction is desired. It provides for immediate and reliable wound closure, with no additional donor site. Tissue expander placement can then be applied six weeks later to achieve the hair-bearing closure. Free tissue transfer could be used in this circumstance as well but has the additional donor site morbidity and operative time that is unnecessary.
Integra also allowed for the reconstruction of multiple different simultaneous scalp defects. This was especially useful in patients with an extensive history of cutaneous head and neck cancers from prior sun exposure or the immunosuppressed patient with a history of prior transplant surgery. Multiple defects could be addressed at the same time, reducing the need for multiple procedures. It was also a useful tool in cases where there was high suspicion for recurrence, and free tissue transfer could be saved for use later on.
Reconstruction with Integra would not be an ideal long-term reconstruction in a patient with full-thickness scalp and full calvarium defect with exposure of the underlying dura. Abbas Khan et al. described reconstruction of a large full-thickness scalp and calvarial defect that developed due to postoperative ischemia following an aneurysm clipping. Integra reconstruction appeared to be more of a temporizing measure rather than a functional or viable restoration. In addition, Integra cannot be used for a patient where cranioplasty with prosthetic material is planned for calvarial reconstruction. Free tissue transfer must be employed in these cases if there is a co-existing scalp defect.
A limitation in our study and prior institutional studies is the retrospective nature and the lack of a large cohort of patients. In addition, due to the low number of patients in the study, statistical analysis cannot be performed. Therefore, the data should be interpreted as merely an institutional experience and for algorithmic guidance. The data also fails to capture the discussions with patients and families regarding reconstruction options with the final decision made based on individual patient presentation and decision.
Free tissue transfer remains the ideal form of scalp reconstruction, but in patients that have been identified as having higher morbidity associated with a complex reconstruction, Integra can be an alternative reconstructive tool. Success with Integra reconstruction largely lies in the appropriate patient selection.
Data collection, analysis, writing of manuscript, editing: Yang S
Data collection, analysis, editing: Wu MS
Design, analysis, writing of manuscript, editing: Pittman ALAvailability of data and materials
Not applicable.Financial support and sponsorship
None.Conflicts of interest
All authors declared that there are no conflicts of interest.Ethical approval and consent to participate
Not applicable.Consent for publication
Consent was obtained from patients for publication of Figures 6-8.Copyright
© The Author(s) 2021.
1. Tyrell R, Choi YK, Tuncer F, et al. The effects of sequential galeotomies and galea aponeurectomies on scalp flap advancement. Plast Reconstr Surg 2021;147:363e-4e.DOIPubMed
2. Ozturan O, Yenigun A, Senturk E, Calim OF, Aksoy F, Eren SB. Temporal scalp thickness, body mass index, and suprafascial placement of receiver coil of the cochlear implant. J Craniofac Surg 2017;28:e781-5.DOIPubMed
3. Tolhurst DE, Carstens MH, Greco RJ, Hurwitz DJ. The surgical anatomy of the scalp. Plast Reconstr Surg 1991;87:603-4.PubMed
4. Seery GE. Surgical anatomy of the scalp. Dermatol Surg 2002;28:581-7.DOIPubMed
5. Ellis H, Mahadevan V. The surgical anatomy of the scalp. Surgery (Oxford) 2014;32:e1-5.DOI
6. Mehrara BJ, Disa JJ, Pusic A. Scalp reconstruction. J Surg Oncol 2006;94:504-8.DOIPubMed
7. van Driel AA, Mureau MAM, Goldstein DP, et al. Aesthetic and oncologic outcome after microsurgical reconstruction of complex scalp and forehead defects after malignant tumor resection: an algorithm for treatment. Plast Reconstr Surg 2010;126:460-70.DOIPubMed
8. Vatanchi M, Grekin RC. Galeatomy: a useful technique aiding high-tension scalp closures. J Am Acad Dermatol 2019;81:e39-40.DOIPubMed
9. Snow SN, Stiff MA, Bullen R, Mohs FE, Chao W. Second-intention healing of exposed facial-scalp bone after Mohs surgery for skin cancer: Review of ninety-one cases. J Am Acad Dermatol 1994;31:450-4.DOIPubMed
10. Costa DJ, Walen S, Varvares M, Walker R. Scalp rotation flap for reconstruction of complex soft tissue defects. J Neurol Surg B Skull Base 2016;77:32-7.DOIPubMed PMC
11. Onishi K, Maruyama Y, Hayashi A, Inami K. Repair of scalp defect using a superficial temporal fascia pedicle VY advancement scalp flap. Br J Plast Surg 2005;58:676-80.DOIPubMed
12. Freund RM. . Scalp, calvarium and forehead reconstruction. Grabb and Smith’s Plastic Surgery. Philadelphia: Lippincott-Raven 1997.
13. Gürlek A, Alaybeyoğlu N, Demir CY, Aydoğan H, Bilen BT, Oztürk A. Aesthetic reconstruction of large scalp defects by sequential tissue expansion without interval. Aesthetic Plast Surg 2004;28:245-50.DOIPubMed
14. McCombe D, Donato R, Hofer SO, Morrison W. Free flaps in the treatment of locally advanced malignancy of the scalp and forehead. Ann Plast Surg 2002;48:600-6.DOIPubMed
15. Sosin M, Schultz BD, De La Cruz C, et al. Microsurgical scalp reconstruction in the elderly: a systematic review and pooled analysis of the current data. Plast Reconstr Surg 2015;135:856-66.DOIPubMed
16. Leedy JE, Janis JE, Rohrich RJ. Reconstruction of acquired scalp defects: an algorithmic approach. Plast Reconstr Surg 2005;116:54e-72e.DOIPubMed
17. Johnson MB, Wong AK. Integra-based reconstruction of large scalp wounds: a case report and systematic review of the literature. Plast Reconstr Surg Glob Open 2016;4:e1074.DOIPubMed PMC
18. Iblher N, Ziegler MC, Penna V, Eisenhardt SU, Stark GB, Bannasch H. An algorithm for oncologic scalp reconstruction. Plast Reconstr Surg 2010;126:450-9.DOIPubMed
19. Yannas IV, Burke JF. Design of an artificial skin. I. Basic design principles. J Biomed Mater Res 1980;14:65-81.DOIPubMed
20. Schiavon M, Francescon M, Drigo D, et al. The use of integra dermal regeneration template versus flaps for reconstruction of full-thickness scalp defects involving the calvaria: a cost-benefit analysis. Aesthetic Plast Surg 2016;40:901-7.DOIPubMed PMC
21. Seidenberg B, Rosenak SS, Hurwitt ES, Som ML. Immediate reconstruction of the cervical esophagus by a revascularized isolated jejunal segment. Ann Surg 1959;149:162-71.DOIPubMed PMC
22. Lutz BS, Wei FC, Chen HC, Lin CH, Wei CY. Reconstruction of scalp defects with free flaps in 30 cases. Br J Plast Surg 1998;51:186-90.DOIPubMed
23. Altınkaya A, Yazar Ş, Sağlam İ, Gideroğlu K. Reconstruction of extensive scalp defects with anterolateral thigh flap. Ulus Travma Acil Cerrahi Derg 2018;24:364-8.DOIPubMed
24. Lamaris GA, Knackstedt R, Couto RA, Abedi N, Durand P, Gastman B. The anterolateral thigh flap as the flap of choice for scalp reconstruction. J Craniofac Surg 2017;28:472-6.DOIPubMed
25. Lipa JE, Butler CE. Enhancing the outcome of free latissimus dorsi muscle flap reconstruction of scalp defects. Head Neck 2004;26:46-53.DOIPubMed
26. Hierner R, van Loon J, Goffin J, van Calenbergh F. Free latissimus dorsi flap transfer for subtotal scalp and cranium defect reconstruction: report of 7 cases. Microsurgery 2007;27:425-8.DOIPubMed
27. Lin PY, Miguel R, Chew KY, Kuo YR, Yang JC. The role of the anterolateral thigh flap in complex defects of the scalp and cranium. Microsurgery 2014;34:14-9.DOIPubMed
28. Sweeny L, Eby B, Magnuson JS, Carroll WR, Rosenthal EL. Reconstruction of scalp defects with the radial forearm free flap. Head Neck Oncol 2012;4:21.DOIPubMed PMC
29. Gliklich RE, Rounds MF, Cheney ML, Varvares MA. Combining free flap reconstruction and craniofacial prosthetic technique for orbit, scalp, and temporal defects. Laryngoscope 1998;108:482-7.DOIPubMed
30. McLean DH, Buncke HJ Jr. Autotransplant of omentum to a large scalp defect, with microsurgical revascularization. Plast Reconstr Surg 1972;49:268-74.DOIPubMed
31. Labow BI, Rosen H, Pap SA, Upton J. Microsurgical reconstruction: a more conservative method of managing large scalp defects? J Reconstr Microsurg 2009;25:465-74.DOIPubMed
32. Kruse-Lösler B, Presser D, Meyer U, Schul C, Luger T, Joos U. Reconstruction of large defects on the scalp and forehead as an interdisciplinary challenge: experience in the management of 39 cases. Eur J Surg Oncol 2006;32:1006-14.DOIPubMed
33. Ooi AS, Kanapathy M, Ong YS, Tan KC, Tan BK. Optimising aesthetic reconstruction of scalp soft tissue by an algorithm based on defect size and location. Ann Acad Med Singap 2015;44:535-41.PubMed
34. Zhou Y, Jiang Z, Li C, et al. An algorithm for one-stage malignant oncologic scalp reconstruction. Ann Transl Med 2020;8:432.DOIPubMed PMC
35. Bridger AG, O'brien CJ, Lee KK. Advanced patient age should not preclude the use of free-flap reconstruction for head and neck cancer. Am J Surg 1994;168:425-8.DOIPubMed
36. Tarsitano A, Pizzigallo A, Sgarzani R, Oranges CM, Cipriani R, Marchetti C. Head and neck cancer in elderly patients: Is microsurgical free-tissue transfer a safe procedure? Acta Otorhinolaryngol Ital 2012;32:371.PubMed PMC
37. Beausang ES, Ang EE, Lipa JE, et al. Microvascular free tissue transfer in elderly patients: the Toronto experience. Head Neck 2003;25:549-53.DOIPubMed
38. Mitchell CA, Goldman RA, Curry JM, et al. Morbidity and Survival in elderly patients undergoing free flap reconstruction: a retrospective cohort study. Otolaryngol Head Neck Surg 2017;157:42-7.DOIPubMed
39. Nao EE, Dassonville O, Chamorey E, et al. Head and neck free-flap reconstruction in the elderly. Eur Ann Otorhinolaryngol Head Neck Dis 2011;128:47-51.DOIPubMed
40. Bhama PK, Patel SA, Khan U, Bhrany AD, Futran ND. Head and neck free flap reconstruction in patients older than 80 years. J Reconstr Microsurg 2014;30:523-30.DOIPubMed
41. Fancy T, Huang AT, Kass JI, et al. Complications, mortality, and functional decline in patients 80 years or older undergoing major head and neck ablation and reconstruction. JAMA Otolaryngol Head Neck Surg 2019;145:1150-7.DOIPubMed PMC
42. Dasgupta M, Rolfson DB, Stolee P, Borrie MJ, Speechley M. Frailty is associated with postoperative complications in older adults with medical problems. Arch Gerontol Geriatr 2009;48:78-83.DOIPubMed
43. Wang JC, To EW. Application of dermal substitute (Integra) to donor site defect of forehead flap. Br J Plast Surg 2000;53:70-2.DOIPubMed
44. Spector JA, Glat PM. Hair-bearing scalp reconstruction using a dermal regeneration template and micrograft hair transplantation. Ann Plast Surg 2007;59:63-6.DOIPubMed
45. Gironi LC, Boggio P, Colombo E. Reconstruction of scalp defects with exposed bone after surgical treatment of basal cell carcinoma: the use of a bilayer matrix wound dressing. Dermatol Ther 2015;28:114-7.DOIPubMed
46. Pannucci CJ, Collar RM, Johnson TM, Bradford CR, Rees RS. The role of full-thickness scalp resection for management of primary scalp melanoma. Ann Plast Surg 2012;69:165-8.DOIPubMed PMC
47. Komorowska-Timek E, Gabriel A, Bennett DC, et al. Artificial dermis as an alternative for coverage of complex scalp defects following excision of malignant tumors. Plast Reconstr Surg 2005;115:1010-7.DOIPubMed
48. Wilensky JS, Rosenthal AH, Bradford CR, Rees RS. The use of a bovine collagen construct for reconstruction of full-thickness scalp defects in the elderly patient with cutaneous malignancy. Ann Plast Surg 2005;54:297-301.PubMed
49. Chalmers RL, Smock E, Geh JL. Experience of Integra(®) in cancer reconstructive surgery. J Plast Reconstr Aesthet Surg 2010;63:2081-90.DOIPubMed
50. Richardson MA, Lange JP, Jordan JR. Reconstruction of full-thickness scalp defects using a dermal regeneration template. JAMA Facial Plast Surg 2016;18:62-7.DOIPubMed
51. Abbas Khan MA, Chipp E, Hardwicke J, Srinivasan K, Shaw S, Rayatt S. The use of Dermal Regeneration Template (Integra®) for reconstruction of a large full-thickness scalp and calvarial defect with exposed dura. J Plast Reconstr Aesthet Surg 2010;63:2168-71.DOI
Yang S, Wu MS, Pittman AL. The role of free tissue transfer in reconstruction of full thickness scalp defects. Plast Aesthet Res 2021;8:54. http://dx.doi.org/10.20517/2347-9264.2021.40
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