Reconstruction of Acquired Scalp Defects: An Algorithmic Approach

LEARNING OBJECTIVES: After studying this article, the participant should: 1. Understand scalp anatomy, hair physiology, and skin viscoelastic properties as they relate to scalp reconstruction. 2. Understand the principles that allow for aesthetic reconstruction of scalp defects. 3. Understand the use of local tissue rearrangement for reconstruction of specific areas of the scalp. 4. Understand the use of tissue expansion and free tissue transfer for scalp reconstruction. BACKGROUND: Reconstruction of scalp defects is required for acute trauma, tumor extirpation, radiation necrosis, and the repair of traumatic alopecia or cosmetically displeasing scars. METHODS: The proper choice of a reconstructive technique is affected by several factors-the size and location of the defect, the presence or absence of periosteum, the quality of surrounding scalp tissue, the presence or absence of hair, location of the hairline, and patient comorbidities. Successful reconstruction of these defects requires a detailed knowledge of scalp anatomy, hair physiology, skin biomechanics, and the variety of possible local tissue rearrangements. In nearly total defects, local tissues may be inadequate and tissue expansion or free tissue transfer may be the only alternatives. RESULTS: Plastic surgeons are now able to obtain coverage over the calvaria after the most devastating of defects; however, the challenge to the reconstructive surgeon today is to do so with excellent cosmetic results. Cosmetic scalp reconstruction requires restoration and preservation of normal hair patterns and hair lines. CONCLUSIONS: Successful reconstruction of the scalp requires careful preoperative planning and precise intraoperative execution. Detailed knowledge of scalp anatomy, skin biomechanics, hair physiology, and the variety of available local tissue rearrangements allows for excellent aesthetic reconstruction.