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Yang et al. Plast Aesthet Res 2021;8:54 https://dx.doi.org/10.20517/2347-9264.2021.40 Page 3 of 12

[20]
Studies have shown similar outcomes in terms of the quality of closure technique and in relation to cost .
In addition, Integra has the benefit of spared donor site morbidity, reduced operative time, and reduced
inpatient stay compared to free tissue transfer, making it a viable option for patients who have significant
comorbidities.

Microvascular techniques are certainly utilized in select scenarios at this academic center, a tertiary care
referral center for complex cancer and trauma cases. The purpose of this paper was to evaluate the
frequency of free tissue transfer vs. other techniques such as reconstruction with Integra for the closure of
full-thickness defects of the scalp and associate common factors which led to the reconstructive choice.

METHODS
After obtaining institutional review board approval, a retrospective review was conducted between January
2016 and March 2021. All patients who underwent full-thickness scalp reconstruction at a single tertiary
care institution were identified. Information regarding patient demographic, medical co-morbidities,
smoking history, prior chemotherapy or radiation history, pre-existing coagulopathy, defect etiology, size,
depth, reconstruction type, postoperative complications, and any revision surgery were obtained. Patient’s
calculated American Society of Anesthesiologist (ASA) classification score given by the anesthesia service at
the time of surgery was also recorded to capture the patient’s risk of peri-operative morbidity and mortality.

Defect size was defined as small (< 3 cm), medium (3.1-6 cm), and large (> 6.1 cm). Defect depth was
categorized as full-thickness defects of the scalp and partial or full-thickness defects of the calvarium with
dura exposure. Reconstruction was categorized as either skin graft, Integra only, Integra followed by split-
thickness skin graft (STSG), local flap, regional flap, tissue expander followed by local flap, or free tissue
transfer. Postoperative complications were categorized as acute (occurring during a hospital stay) vs.
subacute (occurring after a hospital stay). Acute complications were more related to free tissue transfer
complications such as arterial or venous thrombosis, flap death, hematoma, infection, or revision surgery.
Subacute complications included skin graft loss, Integra failure, flap necrosis, or infection.

RESULTS
Demographic information
A total of 32 patients with full-thickness scalp and/or partial or full-thickness calvarial defects were
identified for qualitative data review. The average age was 57.88 years (range 3-91), with 22 males (68.7%)
and 10 females (31.2%). All patients were of Caucasian ethnicity. Common medical co-morbidities included
hypertension (n = 15, 46.8%), heart disease, (n = 6, 18.7%), diabetes mellitus (n = 6, 18.7%), chronic kidney
disease (n = 4, 12.5%), obesity defined as BMI between 30 and 40 (n = 6, 18.7%), and severe obesity defined
as BMI > 40 (n = 2, 6.25%). History of anticoagulation use prior to surgery was identified in 7 patients that
underwent reconstruction (21.8%). Three patients (9.4%) were immunosuppressed at the time of treatment,
and nine patients had a prior history of radiation therapy.

ASA scores calculated by Anesthesia at the time of surgery were averaged for Integra patients (2.93 ± 0.25)
vs. free tissue patients (2.75 ± 0.96), see Figure 1. In addition, medical co-morbidities in Integra patients
were compared against free tissue transfer patients in Figure 2.

Reconstruction type
The majority of patients underwent reconstruction with Integra/ Integra + STSG (n = 15, 46.8%) followed by
tissue expander with local flap reconstruction (n = 6, 18.7%). Free flap reconstruction was pursued in 5
patients (15.6%) with 2 latissimus dorsi flaps, 2 radial forearm free flaps, and 1 anterolateral thigh flap. STSG