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Yang et al. Plast Aesthet Res 2021;8:54 https://dx.doi.org/10.20517/2347-9264.2021.40 Page 9 of 12

Figure 7. (A) Multiple full-thickness scalp defects after excision of squamous cell carcinoma. Underlying calvarium drilled until bleeding
bone was exposed. (B) Three weeks after Integra graft placement. The wound demonstrates a bed of healthy granulation tissue. (C)
Three months postoperative visit. The wound healed without skin graft placement.

Figure 8. (A) Large full-thickness scalp defect after dermatofibrosarcoma excision reconstructed with Integra. Silicone sheet removal 3
weeks after Integra placement. (B) Area of exposed bone with incomplete coverage with granulation tissue. (C) Close examination of
the area reveals neovascularization of the bone. (D) The second layer of Integra placed. (E) Three weeks after second Integra
placement, wound bed covered with a meshed skin graft. (F) Four months post-reconstruction.

measure rather than a functional or viable restoration. In addition, Integra cannot be used for a patient
where cranioplasty with prosthetic material is planned for calvarial reconstruction . Free tissue transfer
[20]
must be employed in these cases if there is a co-existing scalp defect.

A limitation in our study and prior institutional studies is the retrospective nature and the lack of a large
cohort of patients. In addition, due to the low number of patients in the study, statistical analysis cannot be
performed. Therefore, the data should be interpreted as merely an institutional experience and for
algorithmic guidance. The data also fails to capture the discussions with patients and families regarding
reconstruction options with the final decision made based on individual patient presentation and decision.