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

Integra Dermal Regeneration Template® has recently emerged in the last few years as an option for scalp
[43]
reconstruction, even for large and full-thickness defects . When there is absent pericranium and exposed
calvarium, Integra allows for immediate closure of wounds without significant associated donor site
morbidity. The outer table of the calvarium can be burred until there is bleeding bone, like what is typically
performed prior to STSG placement . However, prior studies have shown that laying the Integra without
[43]
any burring of the bone does not affect the percent take of the Integra [44-47] . The Integra is laid directly over
the calvarium, and after a delayed period of time to allow for a layer of granulation tissue to form in the
wound bed, a skin graft can be placed over but is not necessary [Figure 7]. Integra placement can be
performed under sedation, limiting the morbidity with general anesthesia. Figure 1 compares ASA scores of
patients who underwent standard of care with microvascular reconstruction vs. a newer method of
reconstruction with Integra. It reveals that patients selected for Integra reconstruction often had elevated
ASA scores. Although the results are not statistically significant, they demonstrate a selection bias toward
pursuing Integra reconstruction in patients with an increased risk of complications with general anesthesia
exposure. Integra has also played a role in reconstructing scalp defects following the excision of malignancy
and previously has been demonstrated to be successful [48-50] . Overall, prior literature has supported the
durability of Integra, reporting 95%-100% graft take even after adjuvant radiation therapy [50,51] .

Our institution recently implemented Integra use as a form of reconstruction during the past two years. A
review of our patients revealed that an overwhelming majority of our large and full-thickness scalp defects
were reconstructed using Integra. These subsets of patients were also found to have a higher ASA score or
numerous medical co-morbidities that would increase the risk of postoperative complications with exposure
to lengthy general anesthesia. We found success in the percentage of graft take and limited donor site
morbidity, especially in patients that had poorer baseline functioning.

The four complications were due to failure for complete graft take with partial exposure of underlying bone.
In all these cases, inconsistent and inadequate pressure was applied over certain areas of the Integra
reconstruction, allowing serous or sanguineous fluid to collect between the wound bed and the graft
[Figure 8]. Like any other skin graft, this prevents attachment and results in graft loss. In patients who
required revision surgery due to inadequate Integra takes, usually, a wound vac was placed over the Integra
to create a complete and consistent seal. We began implementing wound vac placement over large Integra
reconstructions to prevent failure of graft take.

Integra was also noted to be useful for patients in whom hair-bearing reconstruction is desired. It provides
for immediate and reliable wound closure, with no additional donor site. Tissue expander placement can
then be applied six weeks later to achieve the hair-bearing closure. Free tissue transfer could be used in this
circumstance as well but has the additional donor site morbidity and operative time that is unnecessary.

Integra also allowed for the reconstruction of multiple different simultaneous scalp defects. This was
especially useful in patients with an extensive history of cutaneous head and neck cancers from prior sun
exposure or the immunosuppressed patient with a history of prior transplant surgery. Multiple defects could
be addressed at the same time , reducing the need for multiple procedures. It was also a useful tool in cases
[50]
[44]
where there was high suspicion for recurrence , and free tissue transfer could be saved for use later on.
Reconstruction with Integra would not be an ideal long-term reconstruction in a patient with full-thickness
scalp and full calvarium defect with exposure of the underlying dura. Abbas Khan et al. described
[51]
reconstruction of a large full-thickness scalp and calvarial defect that developed due to postoperative
ischemia following an aneurysm clipping. Integra reconstruction appeared to be more of a temporizing