Using Dermal Templates to Safely Reconstruct Complex Calvarial Defects in Patients in their Ninth through Eleventh Decade of Life
Jaime L. Bernstein, MD MS, Jason A. Spector, MD FACS.
NYP-Cornell/Columbia, New York, NY, USA.
PURPOSE: The elderly are the fastest growing portion of the United States population. Plastic surgeons are now more likely to be faced with the need to reconstruct challenging defects in patients in their ninth, tenth, and even their eleventh decades of life. Currently, little to no data exists regarding how to reconstruct or even whether reconstruction should be undertaken for large surface area calvarial defects without remnant periosteum in this "extremely elderly" population. Here we present a case series of patients in their ninth through eleventh decades of life who presented with an avascular, complex scalp defect which was successfully reconstructed using Integra, followed by a split thickness skin graft (STSG).
METHODS: Records were retrospectively reviewed from 2016-2018 and patients were identified who were greater than 80 years old, underwent a complex scalp reconstruction using Integra, followed by a STSG. Four patients were identified who met these criteria.
RESULTS: Four patients with the average age of 93 (86-101) underwent resection of a skin cancer of the scalp (SCC (3), dermal sarcoma (1)) with an average size of 85 square centimeters (40-130) that included the underlying periosteum. All patients had multiple medical co-morbidities, including one with prior brain tumor resection and radiation. All patients underwent a two-stage reconstruction. At the initial stage after tumor extirpation, the wound bed was prepared by burring down the exposed calvarium until there was sufficient punctate bleeding followed by placement of Integra. After an average of 14.5 days, patients underwent placement of a meshed STSG (8/1000th-12/1000th of an inch) over the vascularized Integra. General anesthesia was used for three patients and MAC for one patient. The average surgery times in stage 1 and 2 were 104.5 and 60.25 minutes, respectively. The Integra and STSG took well in every patient with no complications or re-operations required. One patient developed a small area of recurrent SCC for which excisional biopsy was performed and healed completely by secondary intention.
CONCLUSION: Full thickness scalp defects that include the periosteum can be challenging to reconstruct, especially in the elderly. This case series demonstrates that "extremely elderly" patients in their ninth through eleventh decade of life with complex, full thickness calvarial defects are good candidates for reconstruction with integra followed by a STSG. Age should not be a contraindication to complex scalp reconstruction using a dermal template, as this case series demonstrates these patients have the ability to re-vascularize the template and allow a STSG to take with minimal to no complications/morbidity, a relatively short operative time, and stable outcome.
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