Repairs on the scalp may be complicated by relatively inelastic skin and thin dermis that conspire to make closures challenging.
Secondary and tertiary intention healing are frequent options on the scalp, though primary linear closure is preferred when feasible.
Assess the degree of possible tissue movement prior to local anesthetic infiltration.
Attempt to minimize the volume of local anesthetic infused into scalp skin, and consider placing direct pressure on the area after infusion to avoid overestimating the degree of tissue inelasticity.
Superficial excisions on the scalp kept in the suprafollicular plane may heal well via secondary intention healing.
Fascial transposition flaps may be used as an alternative to hinge flaps to provide a vascular bed when periosteum has been removed.
Nerve blocks may be helpful in minimizing the volume of local anesthetic used for select defects.
If a wound fails to show any progress over a 2-week period, assess what is leading to this stagnation and make changes accordingly.
Pitfalls and Cautions
While dog-ears on the scalp tend to resolve spontaneously, concavities do not. Therefore, when using split-thickness skin grafts consider tertiary intention healing to provide time for robust granulation tissue, and thus reconstructive thickness, to form.
Patient Education Points
Patients have variable levels of concern regarding scalp aesthetics; be sure to address this prior to the initiation of surgery.
The scalp healing process may be very time consuming. Patients and their caregivers should be warned about this well ahead of time, and their willingness to undergo a lengthy wound care regimen must be ascertained.
Scalp grafts may be coded with the 15120 and 15220 for split- and full-thickness grafts, respectively. Xenografts may be coded with 15275.
When repairing a scalp defect with a combination flap and graft, both codes may be used. Flap codes may not, however, be combined with linear repair codes.
Reconstructive surgery on the scalp is frequently performed by dermatologic surgeons. Malignancies on the scalp may frequently become large, as they are located on surfaces that are not regularly seen by the patient and that may be covered by hair, often delaying recognition and diagnosis. Additionally, there are unique characteristics of scalp skin and soft tissue that should be considered when designing a closure (Table 44-1).
Table 44-1.Key Considerations for Scalp Reconstruction |Favorite Table|Download (.pdf) Table 44-1. Key Considerations for Scalp Reconstruction
Depth of wound
Presence of adjacent hair-bearing skin
Tensile strength of dermis
Directs the focus of and the extent of the reconstructive effort
Second intention may be ideal for superficial wounds
Represents potential source of scar camouflage