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Page 2 of 12 Yang et al. Plast Aesthet Res 2021;8:54 https://dx.doi.org/10.20517/2347-9264.2021.40

with Integra (n = 3, 100%). Scalp defects with exposed dura were all reconstructed with free tissue transfer (n = 3,
100%). Four Integra-reconstructed patients required revision surgery due to partial graft failure.

Conclusion: Free tissue transfer is widely used to reconstruct large and full-thickness scalp defects. However,
Integra can be a viable option in patients with numerous medical comorbidities or extensive scalp defects requiring
complex reconstruction.

Keywords: Free tissue transfer, full-thickness scalp defects, Integra, scalp malignancy

INTRODUCTION
Acquired scalp defects can be a result of trauma, burns, tumor resection, chronic non-healing wounds, or
radiation necrosis. Defects can vary in size and depth. It can involve hair-bearing and non-hair-bearing
skin. Reconstruction is often challenging due to the complex anatomy of the scalp.

Anatomy
Scalp thickness ranges from 8 to 13 mm, often thicker in patients with advanced age, males over females,
[1,2]
and increasing levels of body mass index (BMI) . The layers of the scalp have been well described in
previous literature and remembered by the mnemonic “SCALP”: S - skin, C - connective tissue, A -
[3-5]
aponeurotic layer, L - loose connective tissue, and P - periosteum .

The skin covering the scalp often contains hair follicles and numerous sebaceous glands. The connective
tissue layer is where the dense vascular supply of the scalp is located, resulting in the richest blood supply of
[5]
any area of the skin in the body . Branches of the internal and external carotid arteries contribute,
including the supraorbital and supratrochlear vessels (internal carotid artery) and the superficial temporal,
posterior auricular, and occipital vessels (external carotid artery) . The aponeurotic layer is also known as
[6]
the galea and is the source of strength of the scalp. This thick connective tissue layer results in the scalp
[7]
inelasticity and the convex shape of the skull, making closure with local flaps more difficult . Galeotomies
or galeal scoring techniques can be used to relax and reduce tension during closure . In addition, the loose
[8]
connective tissue accounts for the mobility of the scalp over the underlying skull. Lastly, the periosteum
over the skull, also called the pericranium, is responsible for providing nutrition to the bone.

Reconstruction
Reconstruction of scalp defects can range from nothing with healing by secondary intention , simple
[9]
[10]
reconstruction such as primary closure, local rotational flaps or advancement flaps , skin grafting
[11]
[12]
[13]
(partial vs. full-thickness) , tissue expansion , to more complex procedures such as microvascular free
tissue transfer .
[14]
The factors that may contribute to using free tissue transfer for scalp reconstruction include a large defect
size, full-thickness scalp defect down to calvarium, full or partial thickness defects of the calvarium, previous
treatments such as radiation, or patient-related factors [15,16] . The main goal of free tissue reconstruction is to
cover the defect with vascularized soft tissue and limit donor site morbidity. Depending on patient age, co-
morbidities, and defect size, certain reconstruction options may be a more suitable choice [17,18] .

In recent decades, the Integra Dermal Regeneration Template® has been utilized as an option for the
reconstruction of complex scalp defects, even with exposed calvarium. It is an artificial dermis composed of
[19]
a bovine collagen/glycosaminoglycan polymer lattice covered by a thin synthetic silicone epidermis . This
has provided an alternative to defects that otherwise would have been closed with free tissue transfer.