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Comparative Outcomes For Scalp Reconstruction Following Local Tissue Rearrangement And Biologic Based Wound Matrix
Sammy Othman, BA, Said C. Azoury, MD, Stephen J. Kovach, MD.
Division of Plastic Surgery, University of Pennsylvania, Philadelphia, PA, USA.

Abstract
Background
Scalp reconstruction following full-thickness defects can pose significantly challenging obstacles due to a lack of native tissue mobility and/or tissue damage secondary to irradiation in the presence of cancerous lesions. The risk of chronic calvaria exposure and consequent brain vulnerability makes soft-tissue coverage of the scalp of critical importance. Local tissue rearrangement and Bilayer Wound Matrix (BWM) (Integra) have traditionally been harvested as soft-tissue repair modalities for wounds of several anatomical locations due a variety of etiologies, including cancer, trauma, and burns. Although both methods have reported success in preventing further calvarial exposure, to date, the optimal repair modality has not been comparatively described.
Methods
A retrospective chart review was conducted encompassing all patients requiring soft-tissue reconstruction secondary to scalp wounds from January 2010 to June 2019. Patients were further identified and grouped based on repair modality either Integra or local tissue-rearrangement. Patient demographics, comorbidities, wound etiology, wound age, defect size and post-operative healing outcomes were all recorded. Patients were then matched in each group based upon defect size. Outcomes including 90-day exposure rates, re-operative rates, and wound complications were examined and compared between the two modalities.
Results
A total of 180 patients undergoing soft-tissue reconstruction with either Integra or local tissue-rearrangement following scalp defects were identified. Following patient matching, 56 patients were deemed appropriate for analysis with a mean defect size of 72.8 square centimeters. Patients were an average age of 64.8 years old, with 60.7% being male. The mean body mass index (BMI) was 26.1, with 19.6% being obese (>30 BMI). Other common comorbidities include hypertension (50%), smoking status (48.2%), diabetes mellitus (19.6%), chronic kidney disease (10.7%), immunosuppression (16.1%), peripheral artery disease (14.3%), and hyperlipidemia (25%). Additionally, 17.8% of patients underwent pre-operative radiation. These rates did not differ significantly between groups. On analysis, the Integra repair group underwent a 17.9% rate of re-operation, excluding split-thickness skin grafting, while the local-tissue rearrangement group had a rate of 10.7% (p > .05). The Integra group had a significantly higher rate of re-exposure at 90 days (28.7%), compared to the local tissue rearrangement group (3.6%) (p = .025)
Conclusions
Local tissue rearrangement for scalp wounds provides superior soft-tissue coverage for scalp wounds in an intermediate time frame compared to Integra Bilayer Wound Matrix. Although rates of re-operation are similar between the two, the risk of wound break and consequent calvarial exposure is higher with Integra. The authors recommend the use of local tissue rearrangement where available for moderate defect sizes.


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