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Central (Vertex) Defects
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e
f
Fig. 5.11 (continued)
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5 Scalp Reconstruction
Fig. 5.11 (continued)
i
Central (Vertex) Defects
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Split Skin Graft
Indication: Medium and large defects the vertex and lateral scalp. Could be considered when the native bed has a compromised blood supply (e.g. exposed bone),
secondary defects.
Technique: A graft of suitable thickness and size is harvested with a dermatome
from the donor site. It is vitally important that the surfaces are accurately oriented
to avoid ap failure. The graft is laid in the defects, with the graft overlapping of the
defect margins. The margins are sutured into place with a resorbable suture, with
additional suture left long to be used for “tying” over the bolus dressing. A nonadherent dressing is laid over the sutured graft, over which a cotton wool ball/
sponge soaked in proavin or a suitable antibiotic ointment is paced. The tie-over
bolus sutures are now used to hold the dressing in place. Alternatively, the dressing
could be held with skin staples (Fig.5.12a–g).
Tips: Deciding on the thickness of the graft depends on the vascularity of the
bed, the stresses that it is likely to encounter in the recipient site and the size of the
defect. A split skin graft can be considered when a pericranial ap is used to cover
exposed bone prior to grafting and when the outer table is “burred” to expose the
dipole and a transposition ap is not considered to cover the defect.
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ab
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5 Scalp Reconstruction
c
d
Fig. 5.12 Split skin graft. (a) Markings for excision, (b) Excision defect, (c) Skin graft sutured in
situ with “stab” holes, (d) Tie over bolus dressing, (e) Secondary scalp defect, (f) Split skin graft
(g) Split skin graft in situ
Central (Vertex) Defects
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e f
Fig. 5.12 (continued)
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g
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5 Scalp Reconstruction
Integra® andSkin Grafting
Indications: Defects with exposed bone, unable to line base with pericranial ap,
likely to receive radiotherapy following skin graft reconstruction.
Technique: A suitable template is made of the defect and an appropriate size of
Integra® cut. The Integra® is prepared according to the manufactures instructions
and sutured into the defect. Care is taken to place the Integra® the correct way over
the defect. A tie-over dressing with sponge and antibiotic paste is used to hold the
Integra in place. Wound care advice is provided, and the wound reviewed regularly
for signs of infection. The dressing is removed in 4weeks’ time and the wound
inspected for vascular ingrowth. If satisfactory, the supercial surface is gently
scrubbed/curetted, and a split skin graft placed (Fig.5.13a–j).
Tips: Meticulously follow the manufacturers instruction. Profusely irrigate and
gently scrub the surface of the Integra® prior to skin grafting at the second stage.
ab
cd
Central (Vertex) Defects
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Fig. 5.13 Integra® with split skin graft. (a) Markings for excision, (b) Excision defect down to
bone, (c) Depth orientation grooves for removal of outer cortex, (d) Defect following removal of
outer cortex, (e) Integra® being prepared according to manufacturers instructions, (f) Sutured into
place with silicone layer in situ, (g) Pressure dressing in situ, (h) Second stage - excellent vascular
ingrowth of Integra®, (i) Split skin graft sutured in situ, (j) Complete “take” of skin graft
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gh
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5 Scalp Reconstruction
e
f
Fig. 5.13 (continued)
ij
Central (Vertex) Defects
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Fig. 5.13 (continued)
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5 Scalp Reconstruction
Pericranial Flap andSkin Grafting
Indications: Defect with exposed bone when a skin graft is planned.
Technique: The margins of the existing defect are widely undermined and/or
additional incisions made and the scalp ap raised in the sub-galeal plane, taking
care not to perforate the underlying pericranium. An appropriately oriented pericranial ap is raised on a broad base and transposed into the defect. The skin incisions
are closed rst, and residual defect lined by the pericranium, is covered with a split
skin graft. The graft is held in place with appropriate dressing (Fig.5.14a–o).
Tips: Try and orient the pericranial ap on known vascular pedicles and retain a
broad base. Take care to avoid perforations. Do not allow the pericranium to dry out
and use frequent irrigation while raising and securing the ap.
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