Case I. (a) Before resection of frontoparietal squamous cell carcinoma. (b) CT showed that the tumor had invaded the full-thickness skull and dura mater. (c) The cancerated tissues in the frontoparietal area were extensively resected, while the skull which had been violated and destructed was resected. (d) The scalp flap pedicled with right superficial temporal vessels was designed. (e) The temporal superficial fascia tissue of sufficient width was retained around the superficial temporal vessels to form into a wider vascular pedicle with subcutaneous fascia. (f) The scalp flap pedicled with right superficial temporal vessels was harvested. (g) The pedicled scalp flap was transferred to repair frontoparietal scalp defect. (h) At the second month after surgery
2.3.2 Advancement of Scalp Flap
The advancement of scalp flap is most commonly applied to the repair of scalp defects located in hairline. The transposed scalp flap contains the well-known blood vessels of the scalp, and the area of the scalp flap is not limited to length-to-width ratio, so it belongs to the axial skin flap. The typical transposition of frontoparietal scalp flap supplied blood by the branch of the superficial temporal vessel can repair the scalp defects at the hairlines in the frontal and temporal area, and the length can reach the contralateral region. In the patients with larger scalp defects at the hairlines, the scalp defect can be repaired by advancement of bilateral temporoparietal scalp flaps, and the donor site of scalp flap can be closed directly or through skin graft .
3 Repair of Complex Scalp Defects
3.1 Repair Method
When the malignant tumor locally spreads and invades the deep exocranium or skull, the scope of the tumor resection should be extended to various layers of tissues of the invaded skull, including full-thickness scalp, periosteum and skull, and even the dura mater. It is a more serious complex scalp and skull defects in clinic; the surgery must repair simultaneously defects in dura mater, skull, and scalp to effectively protect the exposed meninges and brain tissue. Repairing the defect wounds in skull and scalp at an early stage is one of the objectives pursued by modern plastic and reconstructive surgery. The commonest dura mater repair usually included the autologous fascia lata graft and the artificial meninges and allogeneic dura mater. Among the materials for repairing the skull defects, in addition to bone tissue such as autologous rib, the biological materials such as titanium alloy grid and Medpor are often used as the alternative materials for skull. These materials should have good biocompatibility as well as reliable hardness and plasticity, and the hardness of the skull can effectively protect the brain and have aesthetic skull appearance. When repairing the skull defects, Plastic surgeons transplant simultaneously the soft tissue flaps with good blood supply to cover the reconstructed skull. These soft tissue flaps can be derived through the abovementioned local scalp flap transfer, or the repair is carried out with free flap transplantation by microsurgical technique. The trapezius myocutaneous flap, free latissimus dorsi myocutaneous flap, and anterolateral thigh flap are often used in clinic. If the range of the scalp defect is too large and the donor site of harvested free skin flap is too broad to be directly sutured, the donor site must be covered by skin graft. However, the skin graft will increase a new wound in skin harvesting area and extend the healing time. In this case, the skin flap in donor site can be designed into 2–3 skin flaps according to the different perforator vessels, and the skin flaps after harvesting are joined together to repair the wound; therefore, the donor site could be closed and sutured directly, which minimizes the damage to the donor site [2–4].
3.2 Typical Case
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Case II. The patient, female, 52 years old, was admitted into the hospital because of recurrence of the parietooccipital scalp leiomyosarcoma at the third month after surgery. The preoperative examination showed that there was a skin graft area slightly on the right side of the parietooccipital area. There were several nodular masses with local skin ulceration in the center of transplanted skin graft, and the whole skin graft was closely adhered to the deep periosteum without mobility. Preoperative examination found no tumor metastasis. The recurrent scalp tumor was extensively resected under general anesthesia, and the full-thickness scalp and periosteum were removed by extending 2 cm along the margin of the original skin transplantation area. During the removal process, the intraoperative frozen section examination was carried out by layers for various layers of removed tissues to guide the scope and layers of the removal. The results showed that the tumor tissue had invaded the meninges, and the removal of all tumor tissues led to defects in scalp and skull and dura mater. The exposed wound of brain tissue was 12 cm × 12 cm. We harvested the latissimus dorsi muscular flap and part of serratus anterior muscle fascia for free transfer to cover the brain tissue, harvested the femoral fascia lata to repair the dura mater defect, used the Medpor biological materials to repair the skull defects, carried out the microvascular transplantation of free latissimus dorsi muscle flap to cover the Medpor, and finally carried out the free transplantation of split-thickness skin graft to repair the scalp wound on the transplanted latissimus dorsi muscle. The body of the patient recovered well after surgery, and the wound healed at the first stage. The removed tissues were definitely diagnosed as leiomyosarcoma of the scalp by the paraffin pathological section examination, and the patient insisted on taking traditional Chinese medicine after surgery. After a four and a half years follow-up, the ulceration appeared at the original surgical site, and a mass was found at the right retroauricular area, which was resected and then was diagnosed as recurrence of scalp melanoma and lymph node metastasis by pathological examination. The patient and her family insisted on reoperation. It was intraoperatively found that the tumor tissue had invaded the original repair tissue, local brain tissue, and sagittal sinus, and all lesion tissues could not be removed completely. Therefore, the burning electric coagulation was performed for the involved tissues at the superficial surface of the brain tissue and sagittal sinus, and the original repair tissue was removed, and then the transplantation of free latissimus dorsi myocutaneous flap was performed under microscopy to repair the scalp defect. The myocutaneous flap survived after surgery, but the inflammatory tissue oozed out under the flap continuously after surgery, and a prolonged unhealed chronic inflammatory sinus tract was formed; thus, only long-term dressing change could be performed to keep the wound clean and maintain smooth drainage under the flap (Fig. 12.2). The patient died of systemic tumor metastasis and multiple organ failure 1 year after surgery.
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