Overview of Scalp Reconstruction
The procedures to reconstruct the scalp can vary from those done for health reasons to those done for improving one’s appearance. Detailed studies have been done on injuries related to scalp damage, and how these are managed. The advancements of scalp reconstruction procedures reflect the progress made in plastic surgery methods, which now includes the use of tissue transfer methods for handling really large injuries.
Common procedures include removing tissues for tests, removing harmless and harmful tumors, and reducing the size of the scalp. Removal for test samples or surgery for benign (non-cancerous) conditions may be applied to scalp conditions like sebaceous nevus, epidermoid cysts, and other harmless pigmented skin lesions. Meanwhile, surgical removal is typically done for malignant (cancerous) conditions include basal and squamous cell skin cancer, Bowen’s disease, Merkel cell carcinoma, and malignant melanoma. The wounds resulting from these procedures might be small and only skin-deep, suitable for direct stitching up. But frequently, they can be large, deep (as deep as the skull bone), and widespread, needing more complex methods for closure.
In the past, scalp reconstruction surgery was used to treat hair loss. However, it’s not often used now due to progress in hair transplant methods. This article does not cover cosmetic procedures.
Scalp reconstruction can follow a specific pattern similar to other plastic surgery procedures. It can involve the wound healing on its own over time (secondary intention); direct suturing; moving nearby tissues to close the wound; using split or full-thickness skin grafts (skin taken from another area of the patient’s body); or using tissue transfer. The decision on which technique or combination of techniques to use may depend on the elasticity of the skin, wound depth and location, and specific condition of the patient (for example, whether they are a smoker, their ability to care for the wound, and overall health). Injuries involving the scalp being torn can occur and be traumatizing. These can be managed with the methods mentioned above, or might potentially need more complicated and more numerous surgeries.
Anatomy and Physiology of Scalp Reconstruction
The layers of the scalp can be described using the acronym SCALP which stands for Skin, Subcutaneous tissue (the layer under the skin), Aponeurotic layer (a tough layer of tissue), Loose areolar tissue (a layer of loosely packed, flexible tissue), and Pericranium (a layer of tissue that covers the skull). Some might refer to the aponeurotic layer as the galea and the loose areolar tissue as just loose connective tissue. The skin of the scalp is as thick as the skin of the rest of the body, and sometimes, it can be used to replace skin in other parts of the body through a skin graft. Blood vessels and nerves are found in the subcutaneous layer of the scalp.
The galea aponeurosis is a strength layer of the scalp, that is connected with the frontalis muscle (a muscle in the forehead), the occipitalis muscle (a muscle at the back of the head), and the temporoparietal fascia (a layer of connective tissue). The scalp is divided into sections based on the anatomy of the underlying skull – the right and left frontal, parietal, vertex, and occipital scalp. It has a lot more hair follicles and pilosebaceous units (units of hair and oil glands) than the face, which helps in quicker recovery of wounds and better hiding of scars.
Most movement of the scalp is possible because of the loose areolar tissue layer. It is easy to dissect and is generally safe as it contains no nerves or blood vessels. However, the movement is restricted at the superior temporal septum (a thick ligamentous area in the lateral frontal region of the scalp) also known as the conjoined or the conjoint tendon. For operations involving scalp lifting, like an endoscopic browlift, these constrictions need to be cut.
There are five main arteries that supply blood to the scalp. The scalp also has veins that are accompanying these arteries and they drain into the veins of the skull and the dural sinuses (channels found between layers of the brain). The scalp also has a network of nerves supplied by the trigeminal nerve and the cervical spinal nerve. Lastly, lymphatic drainage (part of the body’s immune system) in the scalp is carried out by specific lymph nodes – the parotid nodes, submandibular nodes, and deep cervical lymph nodes for the skin at the front of the scalp and the posterior auricular nodes and occipital lymph nodes for the skin at the back of the scalp. That’s important because cancer cells from any malignancies in the scalp can spread to these lymph nodes.
Why do People Need Scalp Reconstruction
If a person has a shallow wound, it can heal naturally by a process known as ‘granulation’. Granulation is a healing method used mostly for shallow wounds, which typically mend within a few weeks. Deep wounds, which reach into the deeper parts of the skin, might take almost two months to heal with this method. It’s useful wherever the wound is and is best for patients who have slow wound healing (like smokers, diabetics, those who’ve had radiation therapy), and those who wish to avoid surgery. In cases of larger wounds, this method is often coupled with a special vacuum system to aid healing.
Next, there is a method known as ‘primary closure’ which is useful for ‘full-thickness’ wounds (wounds that have gone through the entire thickness of the skin). This method can be employed anywhere on the scalp. It works best for wounds that can be stitched up effortlessly in a single surgical sitting.
‘Advancement flap’ and ‘rotational flap’ methods are ideal for full-thickness wounds which can’t be simply stitched up. They work best in cases where there is adequate movable tissue around the wound which can be used to cover it up, and where surgical cuts can be concealed within natural lines or folds in the skin. The only requirement is that patients should be able to tolerate the additional surgery required by these methods.
The ‘transpositional flap’ works in a similar manner, where the flap of skin is moved sideways over normal skin to the wounded area. This too needs an additional surgical procedure.
‘Skin grafts’ come in two forms: split-thickness and full-thickness skin grafts. The split-thickness skin graft (STSG) procedure is used when a full-thickness wound doesn’t easily close with typical stitching or flap methods. This is best suited for patients who have large wounds without a healthy area of blood flow to support a full-thickness graft and are willing to undergo more surgery. Full-thickness skin graft (FTSG) on the other hand is suitable for large wounds which have good blood supply, and here too, patients need to be prepared for more surgeries. Some prefer to use artificial skin instead of the patient’s own skin, but this is not very common.
The ‘free flap’ method helps to heal very large wounds and is the most complex of all methods. These are rare and aren’t a routine practice in skin care medicine.
‘Allografts’ are another option for scalp reconstruction, where tissues are transplanted from a donor of the same species (generally from a cadaver), to prepare the wound for further reconstruction or as a one-time solution.
When a Person Should Avoid Scalp Reconstruction
There aren’t any specific reasons why someone couldn’t have scalp reconstruction surgery. However, if a person has had radiation treatment to the head before, it could make it difficult for the transplanted skin to adjust, as the blood supply could be affected. Also, if someone is in poor health, they might not be able to receive general anesthesia, which is typically used during this type of surgery. This could limit the options for how their scalp is reconstructed. If the skin graft doesn’t take well, it could need some cleaning procedures to remove any non-healthy tissue.
Equipment used for Scalp Reconstruction
To perform a surgery to rebuild the skin on your head (scalp reconstruction), your doctor will need specific tools and equipment, including:
An operating room or clinic, where the procedure will be done. This is a sterile environment to prevent any infections.
A local anesthetic. This is a medication that will numb the area being worked on so you don’t feel any discomfort.
Standard surgical removal equipment, also known as a fine plastic tray. This holds all the small tools the surgeon will need for the operation.
A dermatome which is a tool used by your doctor to peel off and cut thin slices of your skin for grafting (moving to a new place).
Diathermy is used to seal small blood vessels and reduce bleeding by using heat.
A suction tool to keep the surgical area clear of any fluids or small particles that might interfere with the operation.
Different types of sutures (stitches). Absorbable ones will dissolve over time, while non-absorbable kinds will need to be removed by your doctor later.
A pressure bolster, which is a type of bandage that applies pressure to your wound to stop bleeding and promote healing.
And finally, wound dressings to cover and protect your wound after the surgery has been completed.
Who is needed to perform Scalp Reconstruction?
To carry out a reconstruction procedure on the scalp, a team of specialized medical experts is needed. This includes a surgeon who specializes in ear, nose, and throat issues, and a plastic surgeon, who has skills in reconstructing or repairing parts of the body. Also part of the team is an oral and maxillofacial surgeon who focuses on the face, mouth, and jaw. A nurse specialist in head and neck conditions will also be there to provide advanced care. There could also be other doctors who have specialized knowledge about head and neck conditions as part of the team. These medical professionals all work together to ensure the operation goes smoothly and to provide the best care for the patient.
Preparing for Scalp Reconstruction
When treating a problem with the scalp, doctors need to plan and consider all factors before the procedure. This includes whether the patient will need general anesthesia. The medical team will design their action plan carefully, aiming to keep the patient’s hairline natural looking after treatment. They also ensure good blood flow during the treatment and close the wound without applying too much pressure.
Your doctor and care team will do a thorough review of your health history and conduct a detailed check-up. You might also have your picture taken, with your permission, to keep a record. Your doctors will discuss all your treatment options, the risks and benefits of each, and any possible alternatives. They will outline in detail the steps of the procedure to help you understand what to expect through the process.
How is Scalp Reconstruction performed
When a wound is healing by “granulation” or secondary intention, it means that it’s healing from the inside out. The goal is to keep the wound moist, so it’s important to use a ointment or dressing that doesn’t stick to the wound. These should be changed regularly. It’s not recommended to use antibiotic creams or ointments because of the risk of developing a skin allergy. Instead, gently clean and bath the area. Depending on how deep the wound is, healing can take between 2 to 8 weeks. Some larger or deeper wounds might require additional treatments such as a negative pressure wound therapy system.
Primary closure is another method used to close wounds. In this method, the edges of the wound are brought together and stitched up. The wound is shaped like an ellipse, and the length is about three times the width. It’s best to orient the wound along naturally relaxed skin lines – this reduces tension and helps with healing. Stitches are placed both deep within the wound and on the surface to hold it together. If non-dissolvable stitches are used, these will need to removed seven to ten days into healing. Good wound care is necessary during this time.
Advancement and rotational flaps are techniques used to close small wounds when there’s not enough skin nearby to stitch the wound closed. The “flap” of extra skin is moved into the wound and kept healthy by a small strip of tissue called a pedicle. Extra skin that forms little bumps or ‘dog ears’ will need to be removed. Similar techniques like transpositional flaps, where a flap of skin from another area is moved over the wound, can also be used.
Lastly, when the wound is too large for these methods, a skin graft might be required. In a split-thickness skin graft, a thin layer of skin is removed from a donor site and placed over the wound. This is often done when there is a large area to cover. The skin graft is thin and can cover larger areas, and usually heals well. However, it often leaves a patchy white area that doesn’t match the color of surrounding skin. In a full-thickness skin graft, a thicker layer of skin is removed along with some underlying fat tissue and attached to the wound. This type of graft requires careful wound care and might not be successful in all cases.
Possible Complications of Scalp Reconstruction
There can be a few complications after having scalp reconstruction surgery. These include:
– Infection: This is when harmful germs get into your body and cause illness. After surgery, infections can happen in your wound.
– Bleeding: This is when blood leaks out from the area where the surgery occurred.
– Scarring: After surgery, your body heals itself by forming scars.
– Poor cosmesis: This refers to the physical appearance of the surgical area that is not aesthetically pleasing.
– Wound breakdown: Sometimes, the surgical wound may not heal properly, and it starts to open.
– Flap failure: In some scalp reconstruction, a flap of skin is moved to cover the area. Sometimes, this flap doesn’t heal well or survive.
– Graft failure (hematoma/seroma): After surgery, you might have a hematoma or seroma—accumulations of blood or body fluid—which can stop a skin graft from taking correctly. This can cause the graft to fail.
– Need for further surgery: Despite the best efforts, sometimes the results of the first surgery aren’t perfect, and another surgery is needed.
What Else Should I Know About Scalp Reconstruction?
Scalp reconstruction procedures have improved in sync with the overall advancements in plastic surgery. Developments range from handling severe scalp injuries to progress in microsurgery and moving free tissue. Even so, most scalp damages can be managed with local tissue rotational or advancement flaps. These are methods of patching the damaged area using tissue from nearby places on the scalp.
Good surgical plans keep the natural hairline in place and incorporate major blood vessels. Also, after the surgery, the scalp should be closed without any strain on the stitches. These factors all contribute to a successful scalp reconstruction procedure that leaves minimal visible damage or changes to the patient’s appearance.
