Abstract
Reconstruction of the scalp following oncologic resection is a challenging undertaking owing to the variable elasticity of the soft tissue overlying the calvarium and the limited amount of tissue available for recruitment. Defect size, location, and skin characteristics heavily influence the reconstructive options available to the surgeon. Reconstruction options for scalp defects range from simple direct closure, to skin grafting, to adjacent tissue transfer with local flaps, and ultimately to free tissue transfer. Dermal regeneration templates have also gained popularity in the recent past. Often times a primary closure with multiple local flaps can be a prime choice in these scenarios. One such modality of multi-flap closure, the Orticochea flap, is an excellent option for scalp reconstruction as it decreases operative time, may provide hair-bearing skin, and potentially avoids the risks of general anesthesia in debilitated patients. We present an interesting case of a patient with a large scalp defect following melanoma excision that was successfully reconstructed with an Orticochea flap. A review of scalp reconstruction and uses of the Orticochea flap will follow the case presentation.
1
Case presentation
A 61-year old Caucasian gentleman presented to the office with a two year history of a slowly enlarging hyperpigmented lesion of the occipital scalp. The patient reported a history of significant sun exposure. Examination of the scalp revealed a 2.5 cm ulcerated hyperpigmented lesion of the occipital scalp, along with a 1 cm focus of hyperpigmentation anteriorly and a smaller focus of irregular hyperpigmentation posteriorly. The remainder of the head and neck examination, including careful palpation of the neck for adenopathy, was unremarkable.
A punch biopsy of the lesion was performed, revealing malignant melanoma with depth of invasion of at least 0.9 mm, and mitotic index of 1/mm 2 , providing a preliminary tumor stage of at least T1b. A chest roentgenogram was negative, and a PET/CT was positive only for uptake at the primary site.
Options were reviewed with the patient, and the patient elected to proceed with wide local excision of the primary lesion along with a sentinel lymph node biopsy. The patient was taken to the operating room, and sentinel node biopsy was negative for metastatic spread. Following excision of the primary cancer, there was an approximately 100 cm 2 cutaneous defect down to the calvarium ( Fig. 1 ). In order to repair the defect, an Orticochea flap was employed for closure ( Fig. 2 ). The patient required galeotomies and extensive back-cuts given the tightness of the scalp; however, once the flaps were advanced, skin grafting was not necessary as primary closure could be achieved utilizing mechanical creep.
During the postoperative follow up period, the patient did well without any evidence of complication including wound breakdown, recurrence, or flap necrosis. Fig. 3 shows a photograph of the patient’s well healed scalp at five months following surgery.
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Discussion
Scalp defects present in a variety of sizes, locations, and depths, making their reconstruction a regular topic for analysis within the reconstructive literature. Managing these variables alone can make the reconstructive effort challenging. The addition of unique anatomy and complex defects morphs the original reconstructive ladder into a fluid puzzle filled with subtle iterations . Within the early years of scalp reconstruction, the primary focus was healthy tissue coverage – similar to other areas of the body. In the modern era of operative advancements, the focus has shifted to a functional and aesthetically sound reconstruction . This optimized paradigm centers around maintenance of hairlines and hair growth patterns, in addition to maintaining normal tissue thickness – making scalp reconstruction distinct from other regions in the human body. Furthermore, multiple scalp layers create a strong yet extremely inelastic reconstructive canvas, making the critical goal of closure without tension even more important .
The challenge posed to the reconstructive surgeon can be summarized by three idioms – 1) variety of defects and origins, 2) hair line and growth aesthetics, and 3) unique and inelastic native anatomy. Taking the above into account, we approach a scalp defect starting with the natural steps of the reconstructive ladder. Simple direct primary closure is usually limited to small defects < 3 cm, that can be closed with minimal involvement of natural hair lines. If needed, galeal scoring and undermining can be used to ensure a tension free direct primary closure . Secondary intention healing or skin grafting may also be viable options for smaller defects, utilizing healthy periosteum, or when indicated, accessing the diploic bone layer to promote granulation and allow for skin grafting at a second stage. However, the disadvantage of these procedures is that the reconstruction is not hair bearing, and often the native tissue thickness is not reproduced, resulting in contour irregularities. In this particular scenario, dermal regeneration templates can be useful adjuncts to enhance granulation and tissue thickness. Local advancement flaps are the superior option, especially when the defect lies within the area of the scalp amenable to extensive undermining . These flaps can range from the commonly used O to Z or pinwheel flaps, to our focus within this case, the Orticochea flap, sometimes called the “banana-peel” flap . Basing these flaps on a reliable vascular pedicle allows for transfer of significantly larger areas of tissue, and closure of larger defects . Both local and regional pedicled flaps are possible (Juri, supraclavicular, trapezius, etc.). Tissue expansion has become a common and popular technique, allowing hair bearing native scalp to be stretched and then reset on a defect, however serial expansion of the implant is typically required postoperatively, and therefore immediate reconstruction may not be possible. Finally, if complete coverage and tension free closure cannot be attained through regional or local advancements, free tissue transfer is the next viable option. The most commonly described include the latissimus dorsi and anterolateral thigh free flaps . Hair transplantation is a useful adjunct to restore the hairline after reconstruction (reference?), although hair styling and wigs may also suffice.
The Orticochea flap, first described by creator Miguel Orticochea in 1967 and then revisited and altered in 1971, is a local advancement and rotation flap comprised of three mobile segments. The fundamentals of this flap rely on a thorough understanding of the vascular territories of the scalp, and how to maintain perfusion to the three flaps. Often times, galeotomies can allow for adequate expansion and coverage. The Orticochea technique has specific qualities that make it a versatile and useful flap. It allows for coverage of a large defect, repairs like with like, and allows for manipulation of hair lines & borders . When utilizing the Orticochea flap, the surgeon must recognize that in an attempt to further expand each flap, the undermined galeal layer can be perpendicularly scored to allow for greater elasticity. Care must be taken when creating these perpendicular galeotomies not to de-vascularize the rotated flap by injuring the underlying vascular pedicle . It is also important to keep the tips of the individually raised flaps to approximately 90 degrees to prevent risk of vascular compromise as well. The scalp is divided into vascular territories and when initial flaps are opened and undermined, each should include one of the following arterial sources: temporal, occipital, or supraorbital/supratrochlear .
Once the three flaps have coalesced to cover the initial defect, if a residual defect exists from the donor site, it can either be closed with local tissue or a skin graft. If a skin graft is necessary, the donor defect is designed in such a fashion that it lies in the posterior scalp where it is less visible, and care is taken to preserve the periosteum to encourage take of the graft. The use of intraoperative tissue expansion has been mentioned in the literature as a successful way to lengthen flaps. Ultimately, the size of a defect proportionally determines the size of the flaps (larger defects require larger flaps), while the laxity of the surrounding scalp is inversely proportional to the size of the flaps (a tight scalp will require a larger back cut to allow for adequate coverage).
Frodel et al. categorized two distinct groups that benefit from the Orticochea flap – 1) severely debilitated patients who cannot tolerate extended anesthesia, and 2) patients who prefer primary reconstruction with hair-bearing scalp skin . Patients who are unable to tolerate general anesthesia or have significant medical limitations to extended operative times can be suitable candidates to have the procedure done entirely under local anesthesia. Figs. 4, 5 and 6 show intraoperative photographs of a patient with a scalp defected reconstructed with the Orticochea flap under local anesthesia by the senior author (M.A.). With the scalp reconstructive algorithm introduced by Desai et al., the Orticochea flap plays the best role when there is a large (> 30 cm 2 ) frontal or vertex defect, no history of radiation, and no hairline distortion . Utilizing another algorithm approach coined by Leedy et al., the Orticochea flap has a role within occipital and anterior defects, specifically those in which the defect cannot be closed primarily without distortion of the respective hairlines .
