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Brawley et al. Plast Aesthet Res 2022;9:6 https://dx.doi.org/10.20517/2347-9264.2021.107 Page 3 of 14

Figure 2. Innervation and arterial supply of the scalp and head.

SECONDARY INTENTION
Secondary intention is the first option when approaching the reconstructive ladder. This pertains to
granulation and healing of the defect without attempting to close the tissue and skin with sutures. In
patients who are not surgical candidates or have multiple defects, the potential final result of this method
should not be discounted, even in terms of cosmesis [Figure 3]. Ideal conditions include lighter skin color,
baseline alopecia, and a maintained periosteum; however, several studies have shown that secondary
intention is possible yet delayed with an absent periosteum [11,12] . Prolonged wound healing time is an
obvious disadvantage to secondary intention, with others including skin mismatch, telangiectasias, alopecia,
and the risk of osteomyelitis.

Wound vacuum-assisted closure (VAC) has been used in exposed scalp wounds in several case reports,
attesting that wound VACs can accelerate granulation via promoting vascularization, debriding dead tissue,
removing excess fluid, and decreasing bacterial colonization [13-15] . These findings have been corroborated by
a recent meta-analysis and systematic review pertaining to wound VACs vs. standard wound therapy in all
[16]
parts of the body .
PRIMARY CLOSURE
Primary wound closure should be considered for small defects. Most defects with a diameter less than 3 cm
on the scalp can be closed after wide undermining of the surrounding tissue in the subgaleal plane .
[17]
Wound tension on the hair-bearing scalp can lead to alopecia. Closure tension should be placed on the galea
since it is the most inelastic layer and is deep to hair follicles . As with all defects undergoing primary
[17]
closure, a fusiform design with a 1:3 width to length ratio between the short and long axis is ideal .
[18]
Standing cutaneous deformities resolve over time generally and can be camouflaged in the hair-bearing
scalp.

SKIN GRAFTING AND BIOMATERIAL
Split- or full-thickness skin grafting are reliable options in the setting of an intact periosteum or granulation
tissue supplied by a vascular bed. Full-thickness grafts can be harvested from the skin overlying level V
cervical lymph nodes depending on skin laxity and redundancy. A dermatome is required for split-thickness
grafts, which are usually harvested from the anterior thigh. A recent case series of over 100 patients noted
no significant difference in graft adherence or complications between the two graft options on the scalp .
[19]
A bolster, which is typically cotton wrapped in petroleum gauze and sutured to surrounding tissue to apply
pressure to the graft, or a wound VAC is required for approximately one week to allow for plasmatic
imbibition, inosculation, and revascularization.