A, Removal of the outer table of calvaria. B, Semipermeable silicone layer of the Integra bilayer wound matrix in place. C, Dual-layer dressing in place and secured with staples. D, One-month postoperative result with 100% skin graft take.
Richardson MA, Lange JP, Jordan JR. Reconstruction of Full-Thickness Scalp Defects Using a Dermal Regeneration Template. JAMA Facial Plast Surg. 2016;18(1):62-67. doi:10.1001/jamafacial.2015.1731
Large full-thickness scalp defects pose a reconstructive problem and commonly require microvascular free flap reconstruction.
To describe a novel and effective reconstructive technique for full-thickness scalp defects that can be performed quickly without general anesthesia or free flap reconstruction.
Design, Setting, and Participants
A retrospective review of 10 patients at a single medical center who underwent surgical resection of a cutaneous lesion. Reconstruction of the large scalp defects included application of Integra bilayer wound matrix followed by delayed split-thickness skin grafting from January 1, 2008, to December 31, 2014. Patients ranged in age from 50 to 87 (mean, 71.5) years; 8 (80%) were men. Mean duration of follow-up was 481.1 days (range, 41-1199 days).
Main Outcomes and Measures
Skin graft viability and adherence to underlying tissue (take) and postoperative complications.
The 10 patients in this study had excellent skin graft and wound closure outcomes. Nine patients showed a 100% initial take of the skin graft to the defect site. Only 1 patient showed a 95% to 100% initial take. Adequate coverage of the wound bed was achieved with acceptable cosmetic results. Two patients underwent postoperative intensity-modulated radiotherapy. One of these patients experienced radiotherapy-induced wound breakdown 3½ months after completion of therapy, which resolved completely after more than 6 months.
Conclusions and Relevance
This novel technique for reconstruction of large full-thickness scalp defects has low morbidity and can be performed on an outpatient basis with minimal wound care. The technique provides the surgeon with an alternative to other reconstructive options, including microvascular free tissue transfer, for repair of large full-thickness scalp defects. The procedure has excellent results and can be performed under sedation and local anesthesia, which avoids the risks associated with general anesthesia.
Level of Evidence
The reconstruction of large full-thickness scalp defects has been a challenge to surgeons owing to scalp anatomy, limited mobility of the scalp, and poor vascularity of the calvaria. Techniques for repair have included primary closure, tissue expansion, skin grafting, local flaps, and microvascular free tissue transfer. Each of these reconstructive options has different limitations and complications. All of these techniques have been described extensively in the literature with proposals of different algorithms1 but with no determination of a single best method. Reconstruction of these defects is often further complicated by the need for radiotherapy for cutaneous malignant neoplasms, which can cause extensive skin changes2 and therefore require the reconstruction to remain viable throughout the course of radiotherapy to prevent complications and revision surgical procedures. During the past decade, surgeons have used artificial skin substitutes or acellular dermal matrix3,4 followed by skin grafting as a new method of reconstruction.
The Integra bilayer wound matrix (Integra LifeSciences Corporation) is a dermal regeneration template that was developed in the early 1980s by Yannas et al5 to address the issues of excessive fluid loss and massive infection in patients with extensive skin loss. Quiz Ref IDThe Integra wound matrix consists of a 2-layer regeneration template of bovine tendon origin. Its outer thin silicone film is a protective layer for the inner porous matrix of cross-linked collagen and glycosaminoglycan, which serves as a scaffold for the regenerating dermis. The US Food and Drug Administration has since approved its use in patients with extensive skin loss (eg, patients with burns)6 and those with complicated surgical wound reconstruction. This dermal regeneration template has been shown to develop blood vessel lumen formation during the third week after application.7 We herein describe our institution’s experience using the Integra bilayer wound matrix followed by delayed split-thickness skin grafting in reconstructing scalp defects.
We performed a retrospective review that included 10 patients who underwent reconstruction of large scalp defects using the application of the Integra bilayer wound matrix followed by delayed split-thickness skin grafting from January 1, 2008, to December 31, 2014. All patients were treated at the University of Mississippi Medical Center and underwent surgical resection of a cutaneous lesion of the scalp that resulted in a large defect. These patients were counseled regarding multiple reconstruction options, including local flaps, healing by secondary intention, and the use of the new technique. Some patients were also counseled regarding the potential for microvascular free flap reconstruction, although many of them were not good candidates for that procedure given their other medical comorbidities and preference for more limited reconstruction. When indicated, imaging was obtained for staging and treatment of a large malignant lesion. Written informed consent was obtained from all patients for a 2-step reconstruction process that included placement of the dermal regeneration template (Integra) followed by delayed split-thickness skin grafting, which was performed several weeks later. Several of these patients were also referred for adjuvant radiotherapy based on the recommendations of the multidisciplinary head and neck tumor conference at the University of Mississippi Medical Center. This study was reviewed and approved by the institutional review board of the University of Mississippi Medical Center.
Patients ranged in age from 50 to 87 (mean, 71.5) years; 8 of 10 patients (80%) were men. The most common lesion was squamous cell carcinoma (4 patients) followed by malignant melanoma (2 patients), basal cell carcinoma (2 patients), microcystic adnexal carcinoma (1 patient), and atypical fibroxanthoma (1 patient). The mean surface area of the defect was 63 cm2 (range, 10-177 cm2) (Table 1). All defects were circular or elliptical, and surface areas were calculated accordingly.
All patients underwent surgical excision of the primary scalp lesion using wide local excision with frozen sections for margin control or the Mohs micrographic technique. All patients underwent a full-thickness scalp resection, including removal of the periosteum overlying the outer table of the skull. To obtain definitively clear margins, several patients underwent removal of a portion of the outer calvarial table using a drill with a cutting burr (Figure, A). If this technique was used, the diploë was left intact as much as possible. In some cases, the wound bed was made slightly smaller through the use of a purse-string suture around the outer edge of the scalp defect. All patients were deemed to have clear margins before reconstruction, and all reconstructive procedures were performed in the operating room. Patients were placed under general anesthesia with an endotracheal tube or given intravenous sedation with local anesthetic. Hemostasis was obtained with bipolar cautery, and the wound bed was irrigated thoroughly with sterile saline solution before reconstruction.
After appropriate preparation of the material according to the instructions of the manufacturer, the Integra bilayer wound matrix was cut to size using a paper template as a guide. The Integra was then placed in the wound bed with the semipermeable silicone layer on the superficial aspect of the wound (Figure, B). The matrix was then coated in bacitracin ointment and secured with 2 dressings (Allevyn; Smith & Nephew, PLC) soaked in gentamicin sulfate solution (160 mg per 200 mL of normal saline solution). The dressing had a nonadherent contact layer, foam core, and outer polyurethane layer that served to protect the wound for the duration of postoperative care. The nonadherent layer allowed for easy removal with minimal disruption of tissue below, whereas the foam core permitted the dressing to be flexible and absorbent. Each layer of the dressing was secured to the surrounding normal skin at the edge of the defect with skin staples. The second layer of the dressing was cut slightly larger than the wound bed to cover and protect the entire wound. This layer was also soaked in gentamicin solution and secured to the surrounding skin with staples (Figure, C).
All patients were seen in the clinic for a wound check at 1 to 2 weeks after placement of the Integra bilayer wound matrix. The dressings were left in place, and patients were instructed to keep the edges of the dressings coated with bacitracin ointment. All 10 patients underwent split-thickness skin graft placement, which was scheduled at the time of their outpatient follow-up visit, after resection and placement of the dermal regeneration template. The mean time from placement of the dermal regeneration template and skin grafting was 21 (range, 14-28) days.
All patients returned to the operating room for placement of a split-thickness skin graft. Quiz Ref IDDuring the second procedure, both layers of the dressing were carefully removed, as was the semipermeable silicone layer on the superficial aspect of the Integra bilayer wound matrix. The wound edges were gently debrided as needed to remove any crusting that may have accumulated, which was generally minimal. A split-thickness skin graft was harvested from the thigh at a thickness of 0.04 cm (0.016 inches) (thicker than often previously described8) and meshed at a ratio of 1:1.25 using a hand-cranked skin graft mesher. The skin graft was then placed into the wound on the superficial surface of the Integra bilayer wound matrix and secured in place at the edges of the wound with 5-0 fast-absorbing gut suture (Ethicon). Bacitracin ointment was then applied on the surface of the skin graft. The wound was again covered with 2 gentamicin-soaked dressings (Allevyn), which were secured with skin staples to the edges of the wound. Patients were instructed to again apply bacitracin ointment to the edges of the dressing. All patients returned to the clinic 7 to 10 days after the second procedure for removal of the dressing and assessment of the skin graft. At that point, patients were instructed to leave the wound uncovered but to apply bacitracin ointment at least twice daily until the wound was completely epithelialized. The mean duration of follow-up was 481.1 (range, 41-1199) days, including several patients who are still undergoing follow-up on a regular basis. Data were analyzed from April 1 to 15, 2015.
The patients in our study had excellent skin graft and wound closure outcomes. Nine of the 10 patients showed 100% initial viability and adherence of the skin graft to the underlying tissues (take) of the defect site. Application of the burr to the outer table of the calvaria was performed for oncologic reasons in 6 of 10 patients and did not appear to affect adherence of the Integra dermal regeneration template to the calvaria or skin graft take. In no case was the outer table completely removed to the diploë. At the time of skin graft placement, the Integra wound matrix was fully adherent to the bone in all cases. Only patient 5 showed a 95% to 100% initial take. Adequate coverage of the wound bed was achieved with acceptable cosmetic results in all patients (Figure, D). Postoperative radiotherapy was recommended in 4 of 10 patients (40%). Two of these patients (20%) underwent the treatments, and the other two opted against any further treatment after reconstruction. Both patients who pursued postoperative radiotherapy underwent intensity-modulated radiotherapy (IMRT). In patient 1 (Table 2), a total dose of 6000 cGy (to convert to rads, multiply by 100) was given in 30 fractions of 200 cGy in a 50-day period. In patient 2 (Table 2), a total dose of 3000 cGy was given in 5 fractions of 600 cGy in a 5-day period. Patient 1 initially healed well with 100% skin graft take but eventually experienced a 6.00-cm2 area of desquamation and cellulitis noted 3½ months after completion of IMRT. This area was treated with hyperbaric oxygen therapy and culture-directed oral antibiotics; the area of skin breakdown improved to be slightly more than half its original size (3.75 cm2) 6 months after IMRT and eventually resolved completely. Patient 2 did not show any breakdown of the graft after IMRT and tolerated the treatment without any major toxic effects.
Full-thickness scalp defects can pose a serious reconstructive challenge depending on the size and location of the defect, skin laxity, hair status, and comorbid medical conditions. Traditional reconstructive techniques have involved local flaps, tissue expanders, and skin grafting. In the past, skin grafting has involved drilling into the diploë and allowing granulation tissue to form to establish an adequate blood supply. Local flaps (usually rotational) are effective for smaller defects, but the poor mobility of the scalp often makes that technique challenging. Although traditional long-term tissue expansion is not feasible for the short-term care of a defect because weeks to months are required to expand the tissue, rapid intraoperative tissue expansion is an option that may assist with closure of difficult large defects. More recently, free tissue transfer with microvascular anastomosis has been favored for larger defects. This method involves substantial risk, hospitalization, and likely increased financial cost.
Several primary benefits of the technique using Integra bilayer wound matrix followed by delayed split-thickness skin grafting can be noted. First, this technique is simple to perform and has a very high rate of success with high-quality cosmetic outcomes. All patients in our study had at least 95% skin graft take, with no wound breakdown or wound-healing issues before radiotherapy. Only 1 patient experienced any wound breakdown, which occurred 3½ months after the completion of IMRT. This breakdown eventually resolved with appropriate wound care and hyperbaric oxygen and antibiotic therapy. Patient 2 (wound area, 63 cm2) experienced no wound problems at any point before, during, or after IMRT despite having a wound with twice the area of patient 1 (31 cm2). Patient 1 received twice the overall IMRT dose compared with patient 2 (6000 vs 3000 cGy), which may have contributed to the delayed wound breakdown experienced by patient 1. Although this reconstruction method was well tolerated in the setting of adjuvant IMRT in both patients, other reconstructive techniques might be better options if the need for postoperative radiotherapy is known in advance. In addition, the 1:1.25 meshing of the split-thickness skin graft provides a high-quality cosmetic outcome. Quiz Ref IDAll split-thickness skin grafts were meshed in these patients because we believe that nonmeshed grafts often have a shiny, atrophic appearance. This shiny appearance is eliminated using the 1:1.25 meshing. Furthermore, the small size of this meshing minimizes the netlike appearance often associated with larger mesh sizes.
This technique is performed on an outpatient basis and requires minimal wound care by the patient. A similar technique was described by Koenen et al9; however, in their series, patients were required to perform dressing changes initially on a daily basis and then at least every 2 to 5 days. Additional dressing changes were also required after skin grafting. Our patients were asked only to apply bacitracin ointment to the edges of the dressing daily and to avoid soaking the dressings if possible. Patients could otherwise proceed with normal daily activities immediately after both surgical procedures. This finding is also in contrast to free flap reconstruction, which generally requires a lengthy surgical procedure and an extended postoperative hospital admission. This admission generally includes close monitoring in the intensive care unit for at least 24 to 48 hours and the care of 2 significant surgical sites. The donor free flap site may also require split-thickness skin grafting depending on the type of free tissue transfer that is used. Many elderly patients have multiple medical comorbidities that make microvascular reconstruction a riskier endeavor compared with the short and relatively noninvasive operative procedure described above. Although not addressed specifically in these data, the above factors likely contribute to a substantial cost savings despite the cost of 2 operative procedures and the use of the Integra bilayer wound matrix.
In addition, we have more recently begun to perform the resection, initial Integra wound matrix placement, and second-stage split-thickness skin graft reconstruction under intravenous sedation with local anesthetic rather than general endotracheal anesthesia. This change may result in quicker postoperative recovery from anesthesia and decreased risk for major anesthesia-related complications in these sometimes frail and elderly patients. We find that patients tolerate intravenous sedation very well. When further surgical procedures are needed aside from surgical excision on the scalp (eg, neck dissection, parotidectomy), patients are placed under general anesthesia with an endotracheal tube.
Several limitations of this technique might make other reconstructive options preferable in some patients. Quiz Ref IDFirst, this technique is not recommended in cases that require full-thickness calvarial resection that results in dural exposure. In such cases, microvascular free flap reconstruction is usually required. In addition, this procedure requires delayed skin grafting, which usually occurs approximately 3 weeks after the initial resection and placement of the Integra bilayer wound matrix. In the series described by Koenen et al,9 skin grafting was performed at approximately 4 weeks. The split-thickness skin graft was successfully performed approximately 1 week earlier and with a graft twice as thick as that described by Koenen et al9 (0.04 vs 0.02 cm [0.016 vs 0.008 inches]). Quiz Ref IDAlthough neovascularization of the Integra bilayer wound matrix has been shown to begin at the end of the second week after application and to be complete by the end of the fourth week, we were successful with split-thickness skin graft application as early as day 14.7
This technique requires 2 surgical procedures, which may be inconvenient and expensive and may expose patients to 2 episodes of anesthesia, even if only intravenous sedation. Although the dressings require minimal care by the patient or caregivers, they are left in place for a total of about 5 weeks combined, which may be socially inhibiting for some patients.
This technique requires a donor split-thickness skin graft site, which results in a second surgical wound and is often painful. In addition, this technique results in the best cosmetic outcome in patients with a large area of non–hair-bearing scalp. Although these patients are often bald or have a limited area of hair-bearing scalp, this technique results in an area of scalp devoid of hair. Local tissue flaps are the preferred reconstruction method for patients with adjacent hair-bearing scalp who desire a cosmetically superior reconstruction.
Investigations into the potential for similar reconstructions in a 1-step fashion that avoid a delayed skin graft have been performed in animal models10 and warrant further study. Finally, this technique also uses multiple wound care products that add to the overall financial cost associated with reconstruction of these scalp defects. Future studies directed at analyzing the cost of this technique compared with alternative reconstructive options are warranted.
In this series, we present a technique for reconstruction of large full-thickness scalp defects that has low morbidity and can be performed on an outpatient basis with minimal wound care. This technique provides the surgeon with an alternative to other reconstructive options, including microvascular free tissue transfer, for repair of large full-thickness scalp defects with excellent results. The procedure can be performed under sedation and local anesthesia for patients with risk factors for general anesthesia.
Corresponding Author: Matthew A. Richardson, MD, Department of Otolaryngology and Communicative Sciences, University of Mississippi Medical Center, 2500 N State St, Jackson, MS 39216 (firstname.lastname@example.org).
Accepted for Publication: September 16, 2015.
Published Online: November 25, 2015. doi:10.1001/jamafacial.2015.1731.
Author Contributions: Dr Richardson had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Richardson, Jordan.
Acquisition, analysis, or interpretation of data: Richardson, Lange.
Drafting of the manuscript: Richardson, Lange.
Critical revision of the manuscript for important intellectual content: Richardson, Jordan.
Statistical analysis: Richardson.
Administrative, technical, or material support: Richardson, Jordan.
Study supervision: Richardson, Jordan.
Conflict of Interest Disclosures: None reported.