Eyebrow Reconstruction in Craniofacial Clefts by Abnormal Hairline Extention.

The absence of eyebrows, whether complete or partial, has been observed in specific types of craniofacial clefts, primarily occurring in Tessier clefts numbers 9 to 13. To address this defect, several techniques have been used to improve eyebrow appearance, such as the island scalp flap and scalp strip grafting technique. However, these methods did not yield satisfactory esthetic results. In this study, the authors present findings from 7 patients with craniofacial clefts, in whom the eyebrows were completely reconstructed through the rotation flap technique, using abnormal frontal hairline extension, in 1 or 2 stages. The result was natural-looking and highly satisfactory, with no associated morbidity.

The role of autologous micrografts injection from the scalp tissue in the treatment of COVID-19 associated telogen effluvium: Clinical and trichoscopic evaluation.

The clinical presentation of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2 COVID-19) varies from asymptomatic infection to a life-threatening, multiorgan disease. One of these manifestations is telogen effluvium (TE) which is characterized by diffuse hair loss occurring in patients previously infected with SARS-CoV-2 and lasts ~3 months, after which excessive hair loss follows. Hair follicles are known to contain a well-characterized niche for adult stem cells which is the bulge containing epithelial and melanocytic stem cells. Stem cells in the hair bulge, a demarcated structure within the lower permanent portion of hair follicles, can generate the interfollicular epidermis, hair follicle structures, and sebaceous glands. This study aims to evaluate autologous micrografts from scalp tissues as a therapeutic modality in the management of TE caused by COVID-19. Twenty patients of previous COVID-19 infection suffered from TE were included in this study for human follicle stem cells micrograft scalp treatment and they were evaluated after 3 months of treatment and after 6 months. There was significant improvement of the hair thickness and density compared with the start of the treatment and 6 months of follow-up. Autologous micrograft of the scalp showed marked improvement in the treatment of COVID-19 TE.

Progenitor-cell-enriched micrografts as a novel option for the management of androgenetic alopecia.

Regenerative medicine is a multidisciplinary field that combines engineering and life science principles to promote regeneration, potentially restoring the physiological condition in diseased tissues. Specifically, the developments of complex grafts enhance the intrinsic regenerative capacity of the host by altering its environment. Autologous micrografts obtained through Rigenera® micrografting technology are able to promote derma and bone regeneration. Androgenetic alopecia (AGA) leads to a progressive thinning of scalp hair affecting 60-70% of the adult population worldwide. Pharmacological treatment offers moderate results and hair transplantation represents the only permanent treatment option. The aim of this study was to demonstrate the role of dermis micrografting in the treatment of AGA by clinical and histological evaluations after 4, 6, and 12 months. Hair growth and density were improved at all indicated times. Those outcomes were also confirmed by the TrichoScan® analysis, reporting an increase of total hair count and density with an increase and reduction of anagen and telogen phases, respectively. Scalp dermoscopic analysis showed an improvement of hair density and histological analysis indicated a clear amelioration of the scalp, development of hair follicles, and a beginning of cuticle formation. Collectively, those results suggest a possible use of the micrografts as a novel therapeutic option in the management of AGA.

Treatment of Large Scars in Children Using Artificial Dermis and Scalp Skin Grafting.

BACKGROUND AND OBJECTIVES: Large scars formed after burns injury can seriously hamper appearance and function in children. Surgical resection of scars and secondary skin or flap grafting often brings severe damages to donor sites, which may lead to physiological and psychological development disorders in children. Here, we introduce the use of artificial dermis and skin grafts from scalps to treat large scars in children to minimize the donor site morbidity. METHODS: A retrospective char review was performed including 7 children with large scars between January 2016 and December 2017. First, the scars were resected, and artificial dermis was applied to the secondary wounds. Twelve days later, outer silicone membrane was removed. Another 2 days later, scalp skin grafts of 0.3 mm were transplanted to the wounds. Manchester Scar Scale and Visual Analog Scale were used to evaluate scar appearance before and after the treatment respectively. One special patient with extensive scars was treated twice at an interval of 1 year. The first therapy was performed with both conventional method of resection and skin grafting and the new method described above. In the second therapy, 4 samples were taken from 4 different sites-the normal skin, scars, the skin where artificial dermis and scalp skin grafting were performed, and the skin where only scalp skin grafting was performed. H-E staining, Masson staining, Aldehyde fuchsin staining, and scanning electron microscopy were used for histological observation. RESULTS: All skin grafts survived well. The Manchester Scar Scale score of the graft area was significantly reduced (P < 0.01) after the treatment. Histological examination showed obviously better dermis arrangement where artificial dermis and scalp grafting was performed. CONCLUSION: The therapy achieves better appearances and minimizes donor site morbidity. It is beneficial to physical and psychological development of children and provides an alternative to treat children with large scars.

Use of Modified Islanded Paramedian Forehead Flap for Complex Periocular Facial Reconstruction.

The paramedian forehead flap is a workhorse flap for reconstructing the nose and periorbital regions. Many variants are described including an islanded flap. However, eyebrow reconstruction is not usually performed with these flaps. The authors describe a patient suffering from postburn scarring medial to the left eye, including loss of the left eyebrow. He underwent a single-stage transfer of the paramedian forehead flap. The flap incorporated scalp hair, which restored the missing eyebrow hair after transfer. The donor defect closed primarily. The paramedian forehead flap is amenable to customization by including a segment of hair-bearing scalp to concomitantly reconstruct the nasal dorsum and eyebrow.

Pentoxifylline intervention and drug action in scalping forehead flap for large temporal cutaneous defects.

Pentoxifylline is widely used in the treatment of cerebrovascular disease, at present, there are a variety of drugs in the clinical expansion of the role of the skin flap, by improving or promoting blood circulation, to ensure the survival of the flap. We designed scalping forehead flap to reconstruct large temporal cutaneous defects. This flap is reliable and can give us excellent postoperative result. This design has several advantages and is worth to be promoted. The scalping forehead flap we designed is reliable. The posterior auricular artery and it branches provided enough blood supply to the scalp and forehead tissue of the flap. The frontal muscle also make the flap have a high survival rate. Large temporal cutaneous defects can be reconstructed by this novel scalping forehead flap we described. This technique is useful especially for patients who suffered malignant tumor and can not choose free flap.

Face transplantation: Complications, implications, and an update for the oncologic surgeon.

Clinical face transplantation, only 10 years old, has evolved into a safe and preferred reconstructive option for the most severe facial defects, in which traditional reconstructive methods have yielded poor outcomes. The ability to simultaneously restore facial function and aesthetics has shown to improve patient's quality of life. Its applicability to post-oncologic resection, however, remains guarded given the current international experience with respect to long term outcomes. J. Surg. Oncol. 2016;113:971-975. © 2016 Wiley Periodicals, Inc.

Alterations in Hair Follicle Morphology and Hair Shaft Production After Follicular Unit Transplantation.

Follicular unit transplantation is the most commonly performed technique in modern restorative hair transplantation surgery. It relies on the acquisition of intact follicular units from microdissected scalp skin strips and their subsequent transplantation into the recipient regions affected by alopecia. Ideally, the translocation of follicular units from the balding-resistant areas of the scalp (usually the occipital region) to the recipient site should not result in any morphological change in the grafts. Nevertheless, the insults associated with surgical intervention present grafted follicles to mechanical and chemical cues differently from those of the physiological steady-state conditions in undamaged skin. This disruption of the normal follicular microenvironment might alter important aspects of hair biology in grafts, for example, hair cycle and pigmentation, and, in turn, could lead to differences in hair appearance, eventually culminating in a diminished esthetical outcome of the surgery. In this study, the authors analyzed native and grafted scalp hair follicles (HFs) from 2 patients who had undergone follicular unit transplantation surgeries formerly. Scanning electron microscopy and light microscopy-based histomorphometry revealed a marked enlargement of follicular structures in the grafts with a concomitant increase in hair shaft diameter. Immunohistological staining confirmed a thickening of the dermal sheath in transplanted HFs that also harbored a denser vascular network. Taken together, these results show that the grafted HFs analyzed were subjected to marked morphological changes during their residence in the recipient site and that this phenomenon is associated with a modulation of follicular vascularization.

Orbitocranial Fibrous Dysplasia: Outcome of Radical Resection and Immediate Reconstruction With Titanium Mesh and Pericranial Flap.

INTRODUCTION: Fibrous dysplasia (FD) is a non-neoplastic developmental fibro-osseous disease. It represents 2.5% of all bone tumors and 5% to 7% of the benign bone tumors. Orbitocranial region is involved in about 20% of the patients. The main presentations are craniofacial deformity and headache. Loss of vision is the most devastating result of this disease. There is no medical treatment to cure or prevent FD. Radiation therapy is contraindicated. Surgery for the orbitocranial FD is often challenging because of the proximity of neurovascular and ocular structures. Conservative surgical shaving and recontouring is always associated with suboptimal results. Radical excision is potentially curative with no extra morbidity. Orbital hypertelorism, dystopia, or proptosis can be corrected only by radical excision and reconstruction. AIM: The aim of the study was to evaluate the outcome of radical excision of the orbitocranial FD and immediate reconstruction using titanium mesh and pericranial flap. PATIENTS AND METHODS: This prospective study had been conducted on 22 patients with orbitocranial FD with age range from 17 to 52 years (mean 29.5). Radical excision of the lesions was done for all patients through transcranial approach. Immediate reconstruction was achieved using titanium mesh and pericranial flap. RESULTS: Intraoperative dural tears and cerebrospinal fluid leak were reported in 2 patients and repaired with galeal graft. Supraorbital anesthesia occurred in 6 patients. Of these, 2 patients were transient, while the remaining 4 patients were permanent. Wound infection was noticed in 1 patient who improved by medical treatment. Temporary postoperative diplopia occurred in 1 patient and temporary postoperative impaired vision in 1 other patient. In all patients, acceptable or good aesthetic results were observed. No recurrence was detected in our series during the follow-up period that ranged from 24 to 58 months (mean 37.5 months). CONCLUSION: Radical excision of orbitocranial FD is potentially curative with no extra morbidity. It can achieve good aesthetic and functional results with no recurrence.

Bipedicled scalp flaps for reconstruction of high-tension electric burns of calvarium.

High-tension electrical calvarial burns are extremely rare and difficult to reconstruct. Invariably, these are third- or fourth-degree-deep burns involving the bone and underlying brain. Historically, these wounds have been treated conservatively, adding to morbidity and prolonged treatment. Two patients with high-tension electrical calvarial burns presented to us 2 weeks after the injury, one fourth-degree deep with infected necrotic calvarium and scalp, resulting in a full-thickness frontoparietal defect with herniation of the brain. The other patient had third-degree burns over the occiput with surrounding second-degree-deep burns extending onto the nape of the neck with patches of second-degree deep burns over the vertex. Both patients had the risk for being subjected to prolonged anesthesia. The defects were covered with bipedicled scalp flap. In the face of sepsis and other comorbidities where more complicated flaps are risky, this flap provides a simple and reliable method of reconstruction.

A 15-year experience of complex scalp reconstruction using free tissue transfer-analysis of risk factors for complications.

PURPOSE: Large, complex scalp defects represent a significant reconstructive challenge, thus a variety of free tissue transfer techniques have been employed to optimally provide soft tissue coverage. The aim of this study is to determine factors associated with complications. METHODS: A retrospective cohort study was performed on patients undergoing free tissue transfer for scalp defects from 1997 to 2011. Patients were compared with respect to demographics, defect characteristics, intraoperative factors, flap choice, and postoperative complications. RESULTS: Forty-three flaps were performed in 37 patients with a success rate of 97.7%. Multivariate regression demonstrated that defect characteristics (size of defect) and patient-related factors (age and smoking) were associated with wound complications in scalp reconstruction. Outcomes were similar between the latissimus dorsi (LD) and anterolateral thigh (ALT) groups and the immediate cranioplasty patients with respect to all forms of complications. CONCLUSIONS: We report a 98% success rate using free tissue transfer for complex scalp defects and identify defect size, patient age, and smoking as factors associated with wound complications. Patient comorbidities were associated with major complications. We report equal efficacy in using the ALT and LD, as well as immediate cranioplasty. LEVEL OF EVIDENCE: Prognostic/risk, level III.

[Clinical study of repairing donor site of thickness from cicatricial skin with auto-scalp grafting].

OBJECTIVE: To study the effects of using auto-scalp for repairing donor site of thickness from cicatricial skin with auto-scalp grafting. METHODS: A total of 13 cases with donor site of thickness from cicatricial skin from January 2011 to December 2011 were analyzed. Wounds of donor site from cicatricial skin were grafted with auto-scalp and scalp were fixation was applied with negative pressure. The survival rate of auto-scalp graft was observed at Day 7 post-operation. At Month 12, hyperplastic scars at these donor sites of cicatricial skin were assessed through Vancouver Scar Assessment Table, scar itch assessment and scar proliferation rate. Wounds in the other thirteen cases with donor site of thickness from cicatricial skin from January 2010 to December 2010 were covered with vaseline gauze as control. RESULTS: No significant difference existed in the gender and age of the two groups patients (P > 0.05). The auto-scalp graft all survived. And the average healing time of donor-site wound in cicatricial skin in grafting group (7 days) was significantly decreased than that of control group (a mean of 20 days) (P < 0.01). After followed up for twelve months, the scar formation assessment value (1.5 ± 0.5), scar itch assessment (1.2 ± 0.4) and scar proliferation rate (14.6% ± 7.6%) in grafting group were significantly less than those of control group (6.7 ± 1.1, 2.0 ± 0.7, 55.8% ± 12.2%, all P < 0.01). CONCLUSION: Auto-scalp grafting may greatly shorten the healing procedure and ameliorate the quality of donor-site of thickness from cicatricial skin.

[Eyebrow reconstruction]. / Ophriopoïèse.

The eyebrow is an essential anatomical area, from a social point of view, so its reconstruction, in case of skin defect, must be as meticulous as possible, with the less residual sequela. Capillary density extremely varies from one person to another and the different methods of restoration of this area should absolutely take this into consideration. We are going to review the various techniques of reconstruction, according to the sex and the surface to cover.

Half forehead reconstruction with a single rotational scalp flap for dermatofibrosarcoma protuberans treatment.

BACKGROUND: Dermatofibrosarcoma protuberans (DFSP) is a soft tissue neoplasm of intermediate to low-grade malignancy. Although metastasis rarely occurs, DFSP has a locally aggressive behavior with a high recurrence rate. In the head and neck area, resection involving a wide margin of healthy tissue can be difficult because of functional and cosmetic considerations. We describe a novel reconstructive method for half forehead defects with an innovative single local wide scalp flap following excision of DFSP with a 3 cm margin of healthy tissue. METHODS: Two patients underwent wide resection of forehead DFSP and reconstruction with a single rotational scalp flap. The scalp flap blood supply was provided from three main vessels: the superficial temporal artery, occipital artery and posterior auricular artery. RESULTS: No early or late complications were observed in either patient with no local recurrence after 18 months of follow-up. The donor area could be closed primarily in both cases and the flaps survived completely. CONCLUSION: This innovative technique allowed a radical excision of forehead DFSP with sufficient healthy margins, thus potentially decreasing tumor recurrence rate. Reconstruction was achieved avoiding microsurgery, skin expanders and large skin grafts. Moreover, all main reconstructive criteria, such as functional and cosmetic tissue characteristics, were completely fulfilled.

Skull base reconstruction using various types of galeal flaps.

BACKGROUND: Failure of skull base reconstruction is a life-threatening issue. This study describes surgical techniques utilising various types of galeal flaps and reports on outcome of these procedures for skull base reconstruction. METHOD: Clinical records of 136 patients (75 men, 61 women; mean age, 50.0 years) who required skull base reconstruction with galeal flaps were reviewed retrospectively. Patients had undergone skull base surgeries with simultaneous reconstruction for benign tumours in 77 patients, malignant tumours in 53, and other lesions in 6. We repaired dural defects using a fascial patch, and covered the skull base defects using various types of galeal flap according to the size and location of the skull base defects. Routine spinal drainage was not used in any patients. FINDINGS: Reconstruction was performed as planned in all patients. We utilised a galea frontalis flap in 17 patients, temporoparietal galeal flap in 95, temporoparietal galeal flap with calvarial bone in 9, and bipedicled temporoparietal galeal flap in 15. Postoperative complications included scalp wound necrosis in 8 patients (5.9%), transient leakage of cerebrospinal fluid in 3 (2.2%), and intracranial infection in 2 (1.5%). Necrosis of the galeal flaps was not encountered. CONCLUSIONS: Galea is a well-vascularised tissue with homogenous thickness. Since the galeal layer covers the entire head area, various types of galeal flap can be elevated to cover any size and location of skull base defect.

Microvascular approach to scalp replantation and reconstruction: a thirty-six year experience.

BACKGROUND: Soft tissue defects of the scalp may result from multiple etiologies and can be challenging to reconstruct. We discuss our experience with scalp replantation and secondary microvascular reconstruction over 36 years, including techniques pioneered at our institution with twin-twin scalp allotransplant and innervated partial superior latissimus dorsi (LD) for scalp/frontalis loss. METHODS: A retrospective review of all patients presenting with scalp loss requiring microvascular reconstruction at a single center was performed from January 1971 to January 2007. Medical records were reviewed for age, gender, defect size/location, etiology, type of reconstruction, recipient vessels used, vein grafts, and complications. RESULTS: Thirty-three patients were identified; mean age was 33 years (range, 7-79). Mean scalp defect size was 442 cm(2) (range, 120-900 cm(2)). Thirty-six microvascular reconstructions were performed; of these, 10 scalp replants and 26 microvascular tissue transfers. Of these 26, 17 were LD based (partial superior LD with and without reinnervation, LD combined with serratus, LD combined with parascapular, LD combined with split rib, LD only) and 2 free scalp allotransplant among others. The superficial temporal artery and vein was used as recipient vessels in 70% of cases. Overall, microvascular success rate was 92%; complications occurred in 14 cases, nine major (tumor recurrence [n = 2], partial flap loss [n = 2], replant loss [n = 3, size <300 cm(2) ], hematoma [n = 2]) and five minor (donor site seroma /hematoma [n = 3], flap congestion [n = 1], superficial wound infection [n = 1]). CONCLUSIONS: Every attempt should be made at scalp replantation when the patient is stable and the parts salvageable. Larger avulsion defects had higher success rates after replantation than smaller defects (<300 cm(2) ), with the superficial temporal artery and vein most commonly used for recipient vessels (P = 0.0083). Microvascular tissue transfer remains a mainstay of treatment for scalp defects, with LD-based flaps, demonstrating excellent versatility for a range of defects.

Reconstruction of a near-total nasal defect using a precontoured titanium mesh with a converse scalping flap.

The reconstruction in case of large nasal defects, especially affecting the cartilaginous portion, is a surgical and aesthetic challenge. The result has to fulfill functional and aesthetic aspects concerning shape, texture, and nasal breathing, which requires accurate reproduction of nasal lining, support, and coverage. Here, we describe nasal reconstruction in a 36-year-old woman after near-total nasal resection due to a malignant peripheral nerve sheath tumor in the glabellar and nasal regions. After tumor resection, the cartilaginous and bone structures were reconstructed using a dynamic titanium mesh, which was precontoured on a three-dimensional-print model of the preoperative situation. Soft tissue defects were covered as a 2-stage procedure using a Converse scalp flap. We achieved an adequate long-term functional and aesthetic and oncological result. Titanium mesh in combination with Converse flap proved to be an alternative in extensive composite midfacial defects.

Aesthetic and anatomic subunit reconstruction of composite mandibular gunshot wound.

BACKGROUND: Gunshot facial traumas involving the mandible and surrounding soft tissues are represented by the potential for loss of relationships between the functional and the aesthetic subunits of the head. METHODS: A patient presented with an 8-cm composite mandibular defect, resulting from a self-inflicted gunshot injury. Taking into account the anatomic/aesthetic subunits involved, a fibular osseoseptocutaneous flap was transferred to reconstruct the left lateral mandibular segment and the floor of the mouth, whereas a preexpanded temporal scalp flap was transferred to restore the hair-bearing skin of the left buccomandibular subunit. A review of the literature is also presented. RESULTS: A satisfactory functional and aesthetic outcome was achieved. Although current literature supports the value of aesthetic subunit face reconstruction and the use of double flaps for the reconstruction of through-and-through oromandibular defects, there is no previous report of the combined use of temporal scalp flap and fibular osseocutaneous flap. CONCLUSIONS: The combined use of hair-bearing skin and osseocutaneous flap may achieve optimal results in through-and-through oromandibular defects.

Facial composite tissue allograft.

Despite complex facial anatomy, transplantation of soft tissues of the entire face, including the maxilla and mandibular segment anterior to the masseter muscle insertion, can be safely performed based on facial vessels alone. Inclusion of hair-bearing scalp requires dissection of the superficial temporal vessels. Unlike other groups, we advocate for supercharging dissected superficial temporal vessels in the preauricular area avoiding difficult dissections in the depth of external auditory canal that presents significant challenges associated with lengthy dissection and bleeding. Neurorrhaphy at the trunk of the facial nerve leads to less targeted postoperative reinnervation, with potential for synkinesis, and whenever possible, individual peripheral facial nerve branches should be reconnected. Adequate planning for integration of the facial allograft requires both complete sensory and motor nerve connection and should be part of each operation. Bilateral external carotid anastomosis may cause a variety of functional problems including oropharyngeal dysfunction and ocular ischemia and hence is not recommended.