Scalp reconstruction with expanded flap

Introduction: The presence of extensive scalp defects is a major reconstructive challenge for the plastic surgeon. These defects have a vast etiology, such as traumatic, thermal or electrical burns, benign and malignant or congenital tumor resections, radiotherapy treatments sequelae, and infections. Noting that injuries such as scalping and burns (thermal or electrical), generate significant repercussions such as severe tissue loss, chronic osteomyelitis or minor sequelae such as scar alopecia. This study aims to report a case of late scalp reconstruction with a tissue expander and posterior advancement flap, due to cicatricial alopecia, in an 11-year-old female, victim of scalding by hot water in the right frontotemporal region. Methods: It was performed a retrospective analysis of the patient’s medical record. The present work follows the standards of the Helsinki ethics committee. Conclusion: The scalp tissue expansion technique by stages and subsequent scalp advancement flap performing proved to be effective in restoring the patient’s hair structure and hairline with minimal local distortion, restoring the scalp’s shape and aesthetics of the patient. ■ ABSTRACT


INTRODUCTION
The presence of extensive scalp defects presents is a major reconstructive challenge for the plastic surgeon 1,2 . These defects have a vast etiology, such as traumatic, thermal, or electrical burns, benign and malignant or congenital tumor resections, radiotherapy treatments sequelae, and infections. Deformities can range from small defects, which can be closed primarily, to extensive defects, which require tissue expansion or even the transfer of a free flap for closure.
Noting that injuries such as scalping and burns (thermal or electrical), generate significant repercussions such as severe tissue loss, chronic osteomyelitis or minor sequelae such as scar alopecia.
In a young female patient, cicatricial alopecia is a very stigmatizing condition in her social life, and may give the patient the experience of intense psychological and social suffering throughout the treatment and throughout her life. It causes significant damage to selfesteem, identity, body perception, humor, sociability, and global affective relationships 3 .
A successful reconstruction plan requires indepth knowledge of the relevant anatomy, careful analysis of the defect, and consideration of various reconstruction options. Each reconstruction plan must be carefully adjusted to meet the patient's specific needs and the characteristics of the associated wound¹.

DISCUSSION
As in the case report in question, the patient desired to have hair in an area of scar alopecia (chronic defect due to thermal scalding burns) in the right parietal and temporal region, it was decided to use gradual tissue expansion with subsequent confection of advancement flap seen to the desired area for local capillary restoration.
The use of tissue expansion is a powerful resource because it allows the surgeon to replace tissue with a similar one. The technique increases the amount of tissue available locally, preserves sensitivity, and maintains hair follicles and attached structures. Defects of up to 50% of the scalp can be reconstructed with minimal distortion of the hairline 1 .
Before inserting a tissue expander, care must be taken to mark the vascular territories on the scalp. Expander placement is not random 1 . In this case, the occipital vessels' vascularization was preserved, and the contralateral vessels were used to make the flap (supratrochlear, supraorbital, superficial temporal, and posterior auricular). In the second week after surgery, 20 ml was instilled weekly for ten weeks until the volume of 240 ml of the expander was reached (Figure 2). After maximum expansion, the patient underwent a new surgical procedure after ten weeks in which the expander was removed, and an advancement flap was made for the region with scarring alopecia (Figure 3). A trichophytic incision was made in the scalp to place the flap on the topography of the hair's cutlet and contour in the frontal-parietal region. The patient evolved well in the early and late postoperative periods without complications (Figures 4 and 5).    The current methodology was the retrospective analysis of the patient's medical record. This paper follows the standards of the Helsinki ethics committee and CEP approval. The main indications for tissue expansion in the scalp are chronic injuries, such as scar alopecia, consistent with our patient's condition. We can also highlight some contraindications to the method, such as acute traumatic injuries or active infectious processes, due to the risk of contamination of the expander and, consequently, its extrusion and loss of result. It is also contraindicated in children under three years of age, as there is the immaturity of the skullcap, which may, during expansion, cause deformities in the bone structure by an external pressure mechanism 8 .
T i s s u e e x p a n s i o n c a n b e p e r f o r m e d intraoperatively or in stages. In the intraoperative period, 3 to 4 cycles of inflation and disinflation of the expander are performed 3 to 5 minutes after placing the device, then, it is removed, and the wound is closed primarily.
A device is placed in the subcutaneous or subgaleal position in the staged technique and connected to a one-way valve. Expansion begins two weeks after placement. The device is expanded weekly or biweekly. The expansion must be continued until the expanded flap is 20% larger than the size of the defect (so that the skull's curvature and the primary contracture of the flap during insertion are taken into account) 1 . This technique was used in the surgical procedure with subsequent removal of the expanding device and making an advancement flap to cover the area of scar alopecia.
There were no early or late surgical complications in this case. The patient evolved well in the tissue expansion procedure, with weekly returns to the doctor's office. After three months, a new surgical procedure was performed to remove the scalp expander, and the advancement flap was made.

CONCLUSION
The scalp scaling tissue expansion technique and subsequent scalp advancement flap preparation proved to be effective in restoring the patient's hair structure and hairline with minimal local distortion, restoring the shape and aesthetics of the patient's scalp.