Deep Plane Fixation in Integumental Surgery

Background. Standard wound closure techniques are prone to complication in the presence of tension.
Objective. To show that deep plane fixation (DPF), a surgical modality based on limited undermining and strategic placement of DPF sutures, affects tension-reduced closure in wounds that would otherwise require skin grafts/flaps or tissue expansion.
Methods. The study is based on an analysis of over 2000 scalp operations.
Results. Two groupings of identical sagittal scalp reductions were done. DPF was used in one and not the other. In the series with DPF, reduced tension closure was consistently possible, as was significantly increased excision, relative to the series without DPF.
Conclusions. DPF narrows the wound base and channels tension forces from superficial to deep and/or nonundermined tissues (where they harmlessly dissipate). This allows relatively increased tissue excision and tension-reduced closure.     

Management of Large Surgical Defects of the Forehead and Scalp by Imbrication of Deep Tissues

BACKGROUND: When facing surgical defects, the dermatologic surgeon follows certain basic principles that help reduce the inherent tension to allow for a better cosmetic outcome. These commonly include the use of undermining, releasing technique such as galeotomy if applicable, selection of suture material of appropriate tensile strength, and closure along relaxed skin tension lines. OBJECTIVE: To review the imbrication of deep tissues, another surgical principle aimed at wound tension reduction and widely utilized by cosmetic surgeons in forehead lifts and scalp reductions, as it applies to dermatologic surgeons in the repair of large surgical defects of the upper face and scalp. The latter may be utilized both with primary closure and with local flaps. METHODS: We describe in detail the technique of imbrication of deep tissues and provide illustrations for a better understanding of how to correctly use this surgical principle. RESULTS: The dermatologic surgeon has an additional tool, termed imbrication of deep tissues, available to aid in the closure of sizable wounds of the forehead and scalp as seen following Mohs surgery for cutaneous malignancies by providing deep tissue support. CONCLUSION: Imbrication of deep tissue is an effective tool that may be used by dermatologic surgeons in conjunction with the more commonly utilized basic surgical principles to enhance the cosmetic outcome in the closure of large, high-tension defects of the forehead and scalp.     

Scalp Surgery: Anatomic and Biomechanical Considerations

BACKGROUND: The purpose of surgery is to effect functional and/or cosmetic benefit while causing as few adverse consequences as possible. At its core lies incision/excision, tissue mobilization, and reconstruction. Each body region presents its own particular surgical challenge. Scalp is made up of collagen, elastin, blood vessels, nerve fibers, and lymphatics with mucopolysaccharide ground substance and tissue fluid, together with hair follicles, sweat, and sebaceous glands. All these elements are anatomically and biologically affected by each modality of surgery. OBJECTIVE: To establish technical guidelines for scalp surgery compatible with maximal functional/cosmetic benefit and complication-free results. METHODS: More than 3000 scalp operations done personally were reviewed. These included the entire spectrum of plastic and reconstructive surgery and hair restoration procedures. RESULTS: Some guidelines compatible with improved scalp surgery results were derived. CONCLUSION: Complication-free scalp surgery is most likely to occur when incisions spare neurovascular structures; do not transect collagen or elastin; undermining is modest and discriminate; deep plane fixation is used; and hair directional orientation (drape) is preserved.     

Galea Fixation in Alopecia Reduction Surgery

BACKGROUND: Alopecia reduction surgery, because of a high incidence of complications, has become a seldom used operation. OBJECTIVE: To show that galea fixation alopecia removal/scalp reduction is simple, safe, highly effective, and largely complication-free. METHODS: Conclusions derived are based on studies of more than 1000 alopecia removal operations, done personally, including 700 performed as part of a surgical research project with specific protocols and goals. CONCLUSIONS: Effective, safe alopecia reduction surgery is possible when incision patterns do not transect either neurovascular structures or collagen and undermining is judicious. Deep plan fixation is regarded as critical to an optimal result.     

Hair Transplantation: Management of Donor Area

BACKGROUND: Hair transplantation entails the removing of a strip of permanent hair from the occipital scalp and reimplanting it piecemeal into the recipient area. Methodologies for effecting this are reasonably complex and have undergone many changes and improvements over the years. The simplest part of hair transplantation, at least in theory, is the removal of the donor strip and closure of the resultant defect. Unfortunately, however, the improvements that have taken place in hair transplantation in general have not spilled over into improved donor area outcomes. Unsightly donor scars and fibrosis are still not only with us, but are possibly even more pervasive than ever. One explanation given for deteriorated donor sites is the harvesting of relatively greater numbers of grafts. But is this the whole story? OBJECTIVE: To describe some technical aspects of donor area management consistent with harvesting the best possible donor strip, while leaving an inconspicuous scar and preserving the viability of the residual tissues for subsequent harvesting. METHODS: In 1994 a clinical research project designed to determine what technical surgical modalities are optimal for excising and reconstructing scalp tissues was commenced. This was done with particular reference to the donor area in hair transplantation. The study involved more than 1000 scalp operations using various techniques and instrumentation, and comparing and contrasting results. RESULTS: The best results were obtained when tissues were least traumatized. Tension generated at wound closure was found to be the main culprit in determining less than optimal residual donor sites. CONCLUSION: Notably improved postharvesting donor sites are most likely to result when measures are taken to ensure minimal trauma by taking definitive steps to combat tension in the tissues. Modest undermining combined with deep plane fixation facilitates channeling of tension vector forces from at-risk superficial tissues into nonundermined tissues and deep tissues, each of which is optimally equipped to withstand the adverse consequences of tension.     

Purse-string closure of scalp defects following tissue expansion: an effective aesthetic alternative.

Primary closure of scalp defects under tension can be complicated by scar widening and alopecia, and large defects usually require the use of local flaps, skin grafts or free flaps. Tissue expansion facilitates the use of local flaps to cover large defects, but multiple expanders and complex flaps with extensive incisions may cause significant scars and alopecia. We describe a purse-string closure of expanded scalp tissue following excision of a large congenital nevus sebaceous. This scalp reconstructive technique minimises iatrogenic scars and uses the predictable forces of scar contracture and skin re-draping to achieve a superior aesthetic result.     

Surgical Anatomy of the Scalp

BACKGROUND: The goal of complication-free scalp surgery remains elusive. Wide unsightly scars, stretch-atrophied hypesthetic, poorly vascularized tissues and distorted hair patterns are still commonly seen and appear to be largely refractory to remedial surgery. OBJECTIVE: To establish technical guidelines for scalp surgery most compatible with maximum functional/cosmetic benefit and complication-free results. METHODS: More than 3000 scalp operations, done personally, were reviewed. These covered the entire spectrum of plastic and reconstructive surgery and hair restoration procedures including more than 700 clinical surgical investigative procedures with pericranial flaps, subgaleal and subperiosteal scalp reductions, and deep plane fixation procedures. RESULTS: Notably improved scalp surgery outcomes resulted from the application of data derived from study of the surgical anatomy of the scalp. Unsightly scars, distorted hair patterns, hypesthetic poorly vascularized tissues, and distorted hair patterns were largely avoided. CONCLUSION: An understanding of the surgical anatomy of the scalp is a cornerstone on which complication-free scalp surgery is based.     

Extended applications for endoscopic forehead surgery

Endoscopic equipment and specially designed elevators and dissecting instruments provide access to the forehead and scalp region through minimal incisions. This technique is now widely accepted for aesthetic forehead and browlifts. To our knowledge, however, it has not previously been used in reconstructive forehead and scalp surgery. We carried out a retrospective review of 5 cases involving patients who underwent reconstructive scalp and frontal bone defect surgery: 2 patients had frontal defects that were contoured with expanded polytetrafluoroethylene (Gore-Tex; WL Gore & Assoc, Phoenix, Ariz) inserted endoscopically; 2 patients had scalp soft tissue defects that were treated with wide subgaleal undermining and endoscopically guided galeotomies that resulted in primary closure; and 1 patient was treated for facial paralysis to improve the aesthetic result. We conclude that aesthetic endoscopic surgical techniques and equipment can be used in reconstructive therapy for patients with bony and soft tissue defects of the scalp and forehead.     

Aesthetic Results of Treatment of Large Alopecia with Total Scalp Expansion

In the last 7 years, 18 patients with large alopecia (approximately one-third of hair-bearing scalp) were treated with 31 tissue expansion procedures. In the previous 44 patients, with various degrees of alopecia treated with conventional tissue expansion technique, the major complication rates were as high as reported in the relevant literature. The clinical experience gained with these cases led us to make some modifications in the surgical technique. We applied some simple surgical maneuvers and Z-plasties to the last 18 cases with large alopecia. The major complication rate of 3.2% observed in this study is comparable to the lower complication rates of 6–12% reported in the literature for different degrees of alopecia. We believe that these simple modifications and meticulous approach improve the results of conventional treatment of alopecia with tissue expansion and flap. In this paper, details of the insertion technique and reconstructive procedures and their relevance to the success rate of the aesthetic treatment of the large alopecia are discussed.     

Surgical treatment of secondary cicatricial alopecia of scalp and eyebrow

Secondary cicatricial alopecia occurs as a result of destruction of hair follicles by scar tissue formed in the scalp and eyebrows. It is a permanent condition and regrowth of hairs in the area is not expected. The purpose of the study was to select the appropriate method for treating cicatricial alopecia. 24 patients were admitted to our hospital during the period from June 2006 to July 2007. They were suffering from acquired cicatricial alopecia affecting the scalp and the eyebrow. Their ages ranged from 6-48 years with mean age 26-25 years. They were treated surgically by total excision of the lesions with direct closure of the defect in ten cases, excision of alopecia with advancement flaps with the aid of scalp expanders in seven cases, scalp reduction through serial excision of alopecia in three cases and excision of alopecia and reconstruction of the defect by strip composite hair-bearing scalp grafts in four cases. Our results suggest there are three key factors that decide the surgical methods for treating alopecia: size, location and shape. We also discuss and evaluate the various techniques of reconstruction. Good results were obtained in 18 patients.     

Technical aspects of war wound excision

Excision of war wounds may be performed by civilian surgeons with no previous experience of war surgery. The principles of complete excision of non-viable tissue with removal of foreign material, leaving the wound open, and delayed primary closure of skin are vitally important. A major part of the surgical approach is wound assessment and the formation of an operative plan. The extent and ease of the operation depends on the site, age and type of wound. Attention to the technique of wound excision avoids septic complications and permits skin closure when the first dressing is removed. Wounds may need re-excision at a later date. Modification of surgical management is necessary when certain difficult areas are wounded and when the patient presents after many days or has suffered inappropriate first aid.     

Malar Fat Pad Elevation: An Aid to Closure

BACKGROUND: In closure of defects inferior to the eye, it is important to avoid inducing lower lid ectropion. OBJECTIVE: To describe a new technique for closure of defects inferior and lateral to the eye. METHODS: A case of malar fat pad elevation to close a post-Mohs surgical defect is described and the procedure is detailed. RESULTS: This technique enabled good wound closure with minimal tension and avoided the complication of ectropion. A transient asymmetry was manifest postoperatively. CONCLUSION: Malar fat pad elevation is an effective and elegant means of closing defects inferior and lateral to the eye. This technique minimizes extensive tissue undermining and movement with its consequences of postoperative tissue swelling, bruising, and hematoma formation. The side effect of ectropion is prevented.     

Scalp reconstruction: a 15-year experience

Scalp reconstruction after ablative surgery can be challenging. A useful reconstructive algorithm is lacking. The purpose of this study was to evaluate the authors' experience and to identify an appropriate reconstructive strategy. This was a retrospective review of all patients treated by the authors' service for scalp defects during a 15-year period. Reconstructive methods, independent factors, and outcomes were analyzed. A total of 73 procedures were performed in 64 patients. Techniques for reconstruction included primary closure, grafts, and local and distal flaps. A correlation between reconstructive technique and complications could not be demonstrated. However, an increased incidence of complications was correlated with a history of radiation, chemotherapy, cerebrospinal fluid leaks, and an anterior location of the ablative defect (P < 0.05). Important tenets for successful management of scalp defects are durable coverage, adequate debridement, preservation of blood supply, and proper wound drainage. Local scalp flaps with skin grafts, and free tissue transfer remain the mainstay of reconstruction in most instances.     

Therapeutic options and postoperative wound complications after extremity soft tissue sarcoma resection and postoperative external beam radiotherapy

Soft tissue sarcomas occur most commonly in the lower and upper extremities. The standard treatment is limb salvage surgery combined with radiotherapy. Postoperative radiotherapy is associated with wound complications. This systematic review aims to summarise the available evidence and review the literature of the last 10 years regarding postoperative wound complications in patients who had limb salvage surgical excision followed by direct closure vs flap coverage together with postoperative radiotherapy and to define the optimal timeframe for adjuvant radiotherapy after soft tissue sarcomas resection and flap reconstruction. A literature search was performed using PubMed. The following keywords were searched: limb salvage, limb‐sparing, flaps, radiation therapy, radiation, irradiation, adjuvant radiotherapy, postoperative radiotherapy, radiation effects, wound healing, surgical wound infection, surgical wound dehiscence, wound healing, soft tissue sarcoma and neoplasms. In total, 1045 papers were retrieved. Thirty‐seven articles were finally selected after screening of abstracts and applying dates and language filters and inclusion and exclusion criteria. Plastic surgery provides a vast number of reconstructive flap procedures that are directly linked to decreasing wound complications, especially with the expectant postoperative radiotherapy. This adjuvant radiotherapy is better administered in the first 3–6 weeks after reconstruction to allow timely wound healing and avoid local recurrence.     

Wedge-Shaped Excision and Modified Vertical Mattress Suture Fully Buried in a Multilayered and Tensioned Wound Closure

Background  A successful deep multilayered wound suture should provide a firm tension-relieving closure, good wound-edge eversion, hemostasis, and minimal intradermal extraneous materials. However, this is not always achieved with a single standard technique. The authors describe their modification of a wound closure method that can rapidly and reliably achieve these results. Methods  A wedge-shaped excision was adopted to obtain a trapezoid pattern transect, after which a modified fully buried vertical mattress suture technique was used to close the wound. These techniques were compared with the standard excision and suture techniques used for the same patient at different times after surgery. Results  The wedge-shaped excision can facilitate good wound-edge eversion, and the modified fully buried vertical mattress suture can provide firm tension relief and optimal apposition. Compared with conventional excision and suture techniques, the described techniques brought about a better outcome in terms of hypertrophic scar prevention. Conclusion  The described modified technique seems to be more efficient than conventional procedures used to prevent hypertrophic scar formation.     

Surgical reconstruction of lentigo maligna defects

OBJECTIVE: To review our experience with lentigo maligna, a melanoma in situ that occurs primarily on the head and neck in older adults, and reconstructive efforts applied in managing the large defects following lentigo maligna excision that are not amenable to primary closure. METHODS: We reviewed the records of 23 patients who underwent serial excision of lentigo maligna using a modified Mohs technique. We compared the sizes of the initial lesion and postexcision defect, examined photographs taken before and after surgery, and studied techniques used in reconstruction. RESULTS: The final surgical defect after staged Mohs excision of lentigo maligna lesions ranged from 2 to 10 times the original lesion size. Invasive melanoma was identified in 2 surgical specimens on pathologic evaluation. We reviewed successful reconstructive techniques including local flaps and tissue expansion. CONCLUSIONS: Surgical excision remains the standard of care for lentigo maligna. Because of the subclinical spread and extensive radial growth characteristic of these lesions, patients are often left with large defects that are not amenable to primary closure. Appropriate preoperative patient counseling includes preparation for the possibility of a large surgical defect that requires staged reconstruction. Creative techniques, including local flaps and tissue expansion, must be in the head and neck reconstructive surgeon's armamentarium for the management of defects following lentigo maligna excision.     

Aesthetic considerations in scalp reconstruction

This article reviews common methods of reconstructive surgery in patients with wounds that involve the scalp, including primary wound repair, healing by secondary intention, and the use of skin grafts, local tissue flaps, regional myocutaneous flaps, and microvascular free flaps. Special attention is paid toward consideration of aspects of the reconstruction that affect the aesthetic outcome, including preservation of the hairline and hair follicle orientation, scar camouflage, avoidance of alopecia, and secondary restoration of alopecia.     

Surgical management of the burned scalp

Alopecia from scalp burns can present psychological problems. Reconstructive surgery with rotating hair-bearing skin flaps has been useful in the rehabilitation of these patients. In many patients, one flap shift can establish an acceptable hair line. In extensive cases, multiple operations are necessary, including fractional excision of small burns that have been skin-grafted or fractional excision of the donor site when large hair flaps were rotated. It is remarkable how the occipital flap can reach the forehead by a series of transfers without delay, using a rotation of 90 to 180 degrees. Worthen presented an interesting case of revascularization of the skull in a victim of an electrical burn. In conclusion, scalding hot liquids accidentally spilled on the young child's scalp will produce a deep burn with loss of hair. Small areas of alopecia that are skin-grafted can be handled by staged fractional excision. The hair line can be reestablished in larger areas of alopecia by a series of operative procedures that require years to accomplish. When the periosteum of the skull is affected, resection of the outer table of bone and skin grafting will expedite wound healing.     

THE DEVELOPMENT OF THE CIRCLE TECHNIQUE FOR DETERMINING THE OPTIMUM LINE OF TUMOUR EXCISION

The healing of skin wounds is markedly influenced by their relationship to the tensional forces in the skin. Directional variations in skin extensibility which give rise to the cleavage line phenomenon and the skin tension lines are easily visualized by a recently developed skin marking technique. This technique makes it possible to plan accurately the optimum line of excision of skin tumours, including malignant melanomata, so as to allow primary linear wound closure without the necessity of undermining or grafting. The technique is particularly applicable to the excision of tumours of the back and limbs, and in addition, provides a warning if the local skin tensional state makes primary closure hazardous.     

Intricacies of the Single-Scar Technique for Donor Harvesting in Hair Transplantation Surgery

BACKGROUND: Although single-scar techniques have been published and are used by approximately half of all surgeons, this approach is not as common as one might suspect. OBJECTIVE: The objective is to demonstrate several surgical gems that make the single-scar donor technique a viable method that can be performed by the vast majority of hair restoration surgeons. METHODS: The author presents various techniques such as postauricular skin elevation, subcutaneous undermining of the nape scalp, debulking of underlying scar tissue, temporary staple closure, and permanent double-layered closure using magnification (preferably 2.5 x or greater). All of these contribute to a loose closure with an aesthetically pleasing single donor scar after multiple surgeries. RESULTS: Utilizing the various techniques described in this article, the author has been able to achieve a cosmetically attractive single scar after multiple surgeries in the vast majority of patients. CONCLUSION: An aesthetically pleasing single, thin donor scar is preferable to multiple scars or a thick single scar at the donor area after multiple hair restoration surgical procedures. The author presents several methods that help hair restoration surgeons conquer some of the obstacles that have deterred them from performing a single-scar technique with consistently excellent results.