Chapter 10 Scalp Reconstruction
The scalp represents one of the most visually homogenous and least anatomically complex regions of the head and neck. However, its unique characteristics and subtleties can often make reconstructive surgery in this area quite challenging. The scalp’s anatomy is unlike the anatomy in any other facial site, and this provides both benefits and drawbacks during reconstruction. The distribution of underlying muscle and the compartmentalization of the scalp by the galea are qualities that distinguish scalp anatomy. The presence of terminal hairs adds yet another unique feature that must be taken into consideration. Primary closures, flaps, and grafts can all be utilized to reconstruct the scalp, though their application techniques can be very different when compared to their uses on other parts of the face. The broad, inelastic nature of the galea, encompassing the scalp as a tendon-like sheath under constant tension, lends the scalp its relative immobility. As such, in comparison to facial skin, extensive undermining is often necessary during scalp reconstruction in order to achieve only small degrees of tissue movement. A thorough understanding of these aspects of the scalp is mandatory for attaining the best surgical outcome.1
SCALP SURGICAL ANATOMY
The scalp extends from the superior nuchal line posteriorly to the supraorbital rims anteriorly and is delineated by the pinnae bilaterally. The scalp is comprised of five layers: skin, subcutaneous connective tissue, galea, subaponeurotic loose areolar tissue, and pericranium. The skin is tethered to the underlying subcutaneous connective tissue and galea by muscle and fibrous bands. Local flaps commonly incorporate the outer three layers of the scalp, and flap undermining is easily performed through the subgaleal space, a relatively avascular plane.1
The galea consists of a thick membranous tendon (galea aponeurotica) that completely encases both the frontalis muscle anteriorly and the occipitalis muscle posteriorly. These muscles are joined in the midline by posterior and anterior extensions of the galea. The galea tightly wraps over the skull because of the antagonistic actions of the frontalis and occipitalis muscles. The temporoparietal muscles originate from the superficial temporal fascia and insert into the lateral border of the galea aponeurotica. Whereas the frontalis/galea/occipitalis are at the depth of the muscles of facial expression, the temporoparietalis is at the deeper level of the muscles of mastication. The subgaleal space lies over the pericranium on the crown of the scalp but extends over the temporoparietalis muscle laterally. This is important, as undermining should be performed in the relatively avascular subgaleal plane above the temporoparietalis muscle and under the frontalis and occipitalis muscles. The scalp areas associated with muscle and fascia exhibit greater mobility than the central regions that consist only of dense underlying galea. As such, more distensible flaps arise from the peripheral scalp, where the skin overlies the frontalis, occipitalis, and temporalis muscles (Figure 10.1).2
Blood vessels and sensory nerves traverse the scalp in a centripetal fashion through the subcutaneous connective tissue layer. The scalp’s abundant arterial supply is derived from the internal carotid system anteriorly (supraorbital and supratrochlear arteries) and from the external carotid system posteriorly (occipital, postauricular, and superficial temporal arteries). The extensive vascular anastomoses allow a single superficial temporal artery to provide sufficient blood supply to virtually the entire scalp; however, the midline scalp possesses a relative watershed zone where perfusion may be less predictable. The scalp lymphatic filtration system interlaces with medium-sized blood vessels in the subdermal and subcutaneous layers. Since the scalp lacks lymph nodes, there are no barriers to lymph flow. Lymph flows in a centrifugal pattern toward the parotid, occipital, preauricular, and postauricular areas.3
The ophthalmic branch of the fifth cranial (trigeminal) nerve provides sensation to the anterior scalp. The occipital nerve, a second cervical nerve derivative, supplies the posterior scalp. The auriculotemporal and maxillary nerves are responsible for sensation to the temple area while the great auricular nerve supplies the postauricular area.1 Infiltrating local anesthetic around the scalp’s periphery (through which all the sensory nerves traverse) can produce total scalp anesthesia.
EVALUATION OF THE SCALP DEFECT
The following questions need to be considered:
What is the depth of the wound? Is the wound through the skin, galea, or periosteum?
Some superficial wounds can appropriately heal by second intention and may even have hair regrowth if the depth of the wound does not extend below the level of the terminal hair bulbs. Most full-thickness wounds will require undermining in the subgaleal plane for tissue movement. Without an intact periosteum, a skin graft will not likely survive unless the underlying bone is burred to induce pinpoint bleeding.4
Is the defect surrounded by hair-bearing or glabrous skin?
BASIC RECONSTRUCTION CONCEPTS
The scalp’s anatomy affords unique reconstructive advantages and disadvantages. The galea aponeurotica is the basis for this uniqueness. This stiff fascial layer is located beneath the subcutaneous connective tissue. Beneath it is the loose subaponeurotic connective tissue, also called the subgaleal space. This plane is relatively avascular, making it ideal for atraumatic undermining (Figure 10.2). Blunt dissection is all that is needed, and this can be achieved by scissor dissection or by simply using one’s gloved finger. This relative ease of undermining can be very deceptive, however, as the degree of additional movement afforded by wide undermining can be surprisingly small. For the best reconstructive outcome, the galea must be fully reapproximated. It is common for less experienced surgeons, particularly when confronted with very tense wounds, to not fully reapproximate the galea. In these cases, the final reapproximation of the wound’s edges involves stretching the overlying skin. The undesirable tension placed on the epidermal edges results in spread and inverted scars (Figure 10.3). It is therefore important that the galea be reapproximated by reaching underneath the leading edge of the defect and grabbing a large bite of galea with the suture needle (Figure 10.4). The strength of a properly realigned galea allows for minimal tension on the overlying skin, which leads to a more aesthetically appropriate scar.1 If proper wound eversion is not also present, the final scar will likely be less than ideal.