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Archive for the ‘scalp reconstruction’ Category

Case Study – Scalp Reconstruction with Custom Skull Implant

Thursday, June 1st, 2017

 

Background: Most scalp reconstructions are done for the need to recreate a full-thickness scalp layer. Replacing a full-thickness scalp wound requires all layers of the scalp and must be done by either tissue expansion or rotation flaps of adjacent scalp or the microvascular transfer of distant tissue.

Most partial thickness scalp defects are missing some of the outer layers, most notably that of the skin. Reconstruction consists of skin grafting which can even be done when the defect is down to the bone. (after creating a vascularized tissue bed)

A far less common partial thickness scalp defect is when an outer skin layer is present but the underlying tissues are thinner. This can occur from avulsive injuries or resections where a subtotal scalp resection has occurred or been performed and then skin grafted.. Such a skin grafted scalp will often look deficient and sunken in, like a ‘bite’ has been taken from the skull.

Case Study: This 35 year-old male had a history of chronic scalp infections on the back of his head. They were so severe that it eventually required excision of all occipital scalp skin and coverage with a large skin graft. This solved his scalp infection issue and he remained infection free ever since. As much of a benefit as this scalp procedure provided it left him looking like he has a skull defect. The back of his head look deficient as if a part of his skull was missing.

To rebuild back his head shape a custom skull implant was designed to push the scalp back out in an ear to ear coverage. A paper template was used to measure the length (24 cms) and height (16cms) of the occipital scalp defect from which a custom skull implants was designed.

Under general anesthesia and in the prone position, an incision was made at the top edge of the skin graft-scalp junction all the way across. A full-thickness inferiorly-based scalp fall was raised down into the neck muscle and back over the back ends of the posterior temporal muscles/fascia. Th custom skull implant has multiple perforation holes placed throughout and the top edge beveled for a smoother fit. It was secured with multiple titanium microscrews and closed with dissolveable sutures. A small drain was placed on both sides.

His head dressing and drains were removed the next day. His immediate result showed a normalization of his skull shape and no vascular compromise of the scalp flap.

Scalp contour defects can be treated by skull augmentation. Custom implants provide an assured and smooth soft tissue effect.

Highlights:

  1. A partial thickness scalp defect that has an intact overlying skin layer can be reconstructed (augmented) with an underlying skull implant.
  2. The design of a custom skull implant for an aesthetic scalp thickness deficiency is based on external measurements.
  1. A limited full-thickness scalp flap can be raised to insert the wrap around skull implant.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Occipital Scalp Roll Excision

Sunday, January 22nd, 2017

 

Background:  The scalp is a remarkably thick and well vascularized tissue as it covers the entire skull surface. Its thickness, however, varies at different areas of the skull. It is the thickest on the back of the head where it blends into the posterior neck tissues. The base of the occipital skull also ends up much higher than one thinks, leading to a thick collection of tissue over the back of the head without any underlying bone support.

Scalp rolls on the back of the head appear to occur due for a variety of reasons. Naturally thick scalp and neck tissues, excessive scalp laxity, short necks and being overweight can all contribute to a bunching up of scalp soft tissues in this area. Scalp rolls can appear as a single, double and even a triple roll. The most common presentation is a double roll with deep horizontal skin crease between them.

Skin rolls on the back of the head is an almost exclusive male aesthetic concern. Shaved heads and very closely cropped hair make them visible and can be a source of embarrassment.

Occipital Scalp Roll Reduction drawings Dr Barry Eppley IndianapolisCase Study: This 28 year-old male had a thick neck with two very prominent scalp rolls with an intervening skin crease with his head in neutral position. It turned into a triple roll when he extended his head backwards. Presurgical markings were made of a elliptical excision incorporating portions of the upper and lower skin rolls with the skin crease at its horizontal middle.

Occipital Scalp Roll Reduction incisionks Dr Barry Eppley IndianapolisOccipital Scalp Roll Reduction Excision Dr Barry Eppley Indianapolis copyUnder general anesthesia and in the prone position, an elliptical excision of scalp skin and a wedge of tissue was removed. The periosteum and some soft tissue was maintained on the bone for subsequent placement of quilting sutures at closure. The upper and lower skin flaps were undermined to release some of the additional skin rolls. Closure was done with quilting sutures to close the deep space as well as up to the skin level where a subcuticular closure was placed.

Occipital Scalp Roll Reduction Immediate result Dr Barry Eppley IndianapolisThis excisional and undermining method will remove most of the skin rolls and create a smoother back of the head contour. While it does create a fine line scar, it appears similar to the horizontal skin crease that already existed.

Highlights:

1) Occipital scalp rolls can have multiple presentations from one to three rolls on the back of the head.

2) Excision of a wedge of skin and deeper tissues allows for scalp roll reduction.

3) Widely undermining the scalp flaps above and below the excised tissues helps to work out adjoining rolls as well.

Dr. Barry Eppley

Indianapolis, Indiana

Fat Injections for Chronic Scalp Pain and Tightness

Monday, October 12th, 2015

 

Tightness and pain after scalp surgery is fairly uncommon. The scalp can become tight after a variety of procedures for aesthetic and reconstructive surgery. Usually these procedures have one thing in common…closure of a scalp wound after tissue loss. The tissue loss may be from removal of a benign or malignant tumor or for a graft harvest for hair transplantation for example. Regardless of the cause, scalp tissues are mobilized and stretched to provide coverage of the defect.

Scalp tightness is hard to treat since there is no way to add tissue. While mobilization and release of the affected scalp tissue may seem like it would work, by itself it just creates as much scar tissue as it releases.

The addition of tissue is the apparent solution to chronic scalp tightness and pain. This is best done through the use of injectable fat grafting. Fat grafts adds new healthy cells and helps create some tissue expansion through its volumetric effect. By stretching the tissues and introducing a variety of soft tissue cells, including stem cells, the fibrotic tissue condition can be improved.

Scalp Scar Release Instrument Dr Barry Eppley IndianapolisFat Injections Scalp Dr Barry Eppley IndianapolisThe scalp is a tight space and does not require large amounts of fat to be effective. It is first necessary, however, to create tissue planes for the fat to be introduced. This can be done using small liposuction cannulas or a picklefork cannula. I prefer the picklefork because it not only breaks up the scalp scar tissue but it creates internal bleeding surfaces which can help improve graft survival by promoting early revascularization.

Fat injections for chronic scalp pain, tightness or other pathologic conditions should be considered to improve the quality of the scalp tissues. It may require multiple fat injections but almost always the scalp can be made more supple.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study: Tissue Expansion in Scalp Reconstruction

Friday, October 11th, 2013

 

Background: The scalp is exposed to a wide variety of traumatic and disease processes which can result in small to large lost segments. While smaller scalp defects can be closed by subgaleal mobilization and stretching to a moderately tight closure, defects beyond a few cms can not be so simply closed with hair-bearing scalp.

Scalp defects that can not be primarily closed requires some method to create more scalp tissue that has hair in it. One option includes rotation scalp flaps but this results in the need for long incisions beyond the defect site and the potential for more problematic scarring. While rotational scalp flaps is a well recognized reconstructive technique and offers a one-stage closure method, the additional scar concerns may be unappealing to some patients.

Another often utilized scalp reconstruction method is tissue expansion. Using differently-shaped and sized balloons implanted as as first stage procedure under normal scalp, the scalp is slowly stretched as small amounts of fluid are added every few days. The scalp responds to tissue expansion very well as the skull bone provides a rigid platform to push off of and stretch out the overlying scalp.

Case Study: This 35 year-old man sustained a partially degloving scalp injury from an automotive accident where a small portion of the scalp was removed. While it was only a partial thickness wound, all hair follicles were lost in the process. The defect size measured 12cm x 5.5 cms.

In a first stage procedure, two small tissue expanders were placed under the scalp on both sides of the defect. They were placed through incisions inside the scalp defect so no additional scalp scars were necessary. Over the next six weeks, small amounts of fluid were added to the expanders until they created enough extra scalp tissue on both sides of the defect.

In a second stage procedure, the scalp defect was excised and the tissue expanders removed. The scalp flaps were mobilized by undermining and the two hair-bearing scalp flaps brought together to cover the previous non-hair bearing scalp. The scalp flaps went out to heal well and the incisional closure did not widen to any significantly visible amount.

Scalp tissue is, by its nature, usually very tight and adherent to the convex underlying skull. While it is easily mobilized at the subgaleal level that does not mean a lot of stretching of the scalp can be done. Often only one to two cms at best can be gained of natural scalp expansion. Even if it can be stretched to close a scalp defect, tension on the scar line will result in substantial scar widening…which will not have hair and as a result becomes a very prominent scar. The use of tissue expanders can help overcome many of these scalp scar problems and is an invaluable aid in many types of scalp reconstruction.

Case Highlights:

1) Loss of hair-bearing scalp can pose a difficult problem for simple excision and closure. If able to be closed the resultant scar often widens significantly.

2) The tightness of the scalp often precludes stretching it to close over an excised area. Tissue expanders help create more scalp tissue for defect coverage.

3) Scalp reconstruction is a two-stage procedure that is spaced at a minimum 3 to 4 weeks apart or longer depending upon how much extra scalp tissue is needed. It has the advantage of no adding to the scar burden and bringing with it hair-bearing tissue.

Dr. Barry Eppley
Indianapolis, Indiana

Instructions for At-Home Scalp Tissue Expander Inflations

Saturday, September 28th, 2013

 

The need for extra or more scalp tissue may be necessary for a variety of aesthetic procedures such as large augmentative cranioplasty (skull buildups) and significant hairline lowerings. (forehead reduction) This is in addition to reconstructive procedures for coverage of scalp defects and removal of scalp tumors. The use of tissue expanders works exceptionally well for the scalp because the underly firm skull bone allows all the expansion to be completely transferred to the overlying scalp tissue.

All adult patients and occasionally some children may have scalp tissue expanders in which the injection port is internal. Most patients can do their own tissue expander injections at home which is a simple and quick procedure to do. The port or dome of the expander will have been placed in a visible area to make it easy to find and visualize for injection. Here are the step by step instructions for doing at home scalp tissue expander injections.

1) Necessary supplies (which will be provided) include: 100cc bags of normal saline, 25 gauge injection needles, 18 gauge withdrawal needles, alcohol wipes, 10cc syringes and plastic bag or container.

2) Remove 100cc bag of normal saline from packaging (outer plastic bag).

3) Attach 18 gauge needle to 10cc syringe by twisting needle onto syringe.

4) Open alcohol wipe and wipe white port on bag of normal saline.

5) CAREFULLY remove cap from needle. Holding the bag of saline with one hand and gently squeezing so the fluid is at the bottom of the bag nearest the port, use your other hand to insert the needle (attached to the syringe) into the white port of the saline bag.

6) Once the needle is inserted into the bag, gently draw back the plunger on the syringe until 10cc of fluid has filled the syringe. Gently remove the needle from the bag and CAREFULLY slide the needle back into the cap.

7) After placing the needle back in the cap, twist the needle to remove it from the 10cc syringe. Collect all needles (once opened and used) in a plastic bag or container.

8) Attach 25 gauge needle to 10cc syringe by twisting needle onto syringe.

9) Using your alcohol wipe, cleanse skin where Expander Port is located.

10) CAREFULLY remove cap from needle. Holding the syringe perpendicular to the port, gently insert the needle into the port. (The needle will meet the resistance of the metal plate in the port once inserted.) It is deeper than you think. Don’t inject until you feel the metal on metal.

11) Gently push the plunger of the syringe and begin injecting the saline to fill your expander.

12) Once 10cc of saline has been injected into your expander, gently remove the needle from the port and CAREFULLY slide the needle back into the cap. Remove the needle from the syringe by twisting and place into the plastic bag or container.

13) Discard your used syringe and alcohol wipe into the trash.

14) Once you have finished with all of your injections, please return your needles to the office so we may safely discard them for you. They should not be discarded in the regular trash.

Ten (10ccs) of saline can usually be added to the expander quite easily and without any discomfort in the beginning. When the expander becomes more filled, towards the end of the inflation period, reducing to 5ccs may be more comfortable.

How much saline is needed to fill the expander and the frequency of the expander injections will depend on scalp expander size and the amount of scalp tissue needed. Usually 200cc scalp expander sizes are needed and most patients have a minimum six week expansion period. Since some fluid is placed into the expander at the time of its insertion (usually 25ccs), enough time is needed to instill around 150ccs of fluid. Thus, expansion injections should be done every 3 to 5 days.

Dr. Barry Eppley

Lora Dillman RN

Indianapolis, Indiana


Dr. Barry EppleyDr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.

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