Forehead, Skull Reconstruction - Hair Restoration Flashcards
A 37-year-old woman who has Fitzpatrick type I skin requests intense pulsed-light therapy for reduction of blond hairs over the upper lip. Compared with a person with darker hair, which of the following best describes the outcome of this procedure?
(A) Decreased risk for permanent scar
(B) Decreased risk for prolonged erythema
(C) Increased risk for hyperpigmentation
(D) Increased risk for malignant transformation
(E) Less effective hair reduction
The correct response is Option E.
Melanin is the target chromophore for laser and intense pulsed-light (IPL) hair reduction. Melanin pigment is responsible for skin and hair color and absorbs energy at wavelengths of 250 to 1200 nm. Thermal injury to the melanin €‘containing cells of the bulb and matrix results in destruction of the hair follicle. Patients with greater melanin content have darker hair and are more likely to have effective laser or IPL hair reduction. In very fair-haired individuals, the limited melanin content makes hair reduction less effective. At higher energy levels, fair-skinned patients can have prolonged erythema. In patients with darker pigmentation, surrounding skin can absorb energy, resulting in blistering or pigment changes.
Which of the following is a CONTRAINDICATION to the use of finasteride as a treatment for premenopausal women with hair loss?
A) Amenorrhea
B) Galactorrhea
C) Hirsutism
D) Masculinization of facial features
E) Pregnancy
The correct response is Option E.
Although FDA-approved for male-pattern hair loss, finasteride is not approved by the FDA for use in women. It is classified as Pregnancy Category X (highest risk) and should not be taken or handled by pregnant women, women who may become pregnant, or those who are breast-feeding. Finasteride has been linked to abnormalities of the external genitalia of a male fetus of a pregnant woman who receives finasteride.
The other choices are not common problems with finasteride, although breast tenderness has been reported.
European studies have selectively used the drug in women for cases of hair loss associated with hyperandrogenism.
A 55-year-old man who has had stable hair loss for the past several years wishes to undergo hair transplantation. Conservative management with administration of finasteride has not been successful. On examination, he has Hamilton’s class 6 male pattern alopecia that extends from the anterior hairline to the vertex. He has dense, curly hair in the parieto-occipital region of the scalp and excellent scalp vascularity and elasticity.
Which of the following is the most appropriate initial management?
(A) Psychological profile and screening
(B) Trial therapy with minoxidil
(C) Establishing the anterior hairline with punch grafts
(D) Establishing the anterior hairline with scalp flaps
(E) Sagittal scalp reduction
The correct response is Option E.
Scalp reduction is currently the most appropriate management of male pattern alopecia. This technique is simple and associated with few complications. Surgical removal of the hairless scalp will diminish the total area that requires grafting and will assist with conservation of donor sites. Although various excision patterns can be used based on baldness pattern, sagittal excision patterns are preferred because they will remove the greatest amount of bald skin due to the excess of scalp laxity seen in the sagittal plane. The surgeon should perform scalp reduction before surgically re-establishing the anterior hairline.
Minoxidil is an antihypertensive drug that has been shown to increase hair growth when applied to the scalp of men who have thinning hair. However, this drug does not work in patients who have extensive hair loss, such as those
Psychological screening is not routinely performed in patients who request treatment of male pattern alopecia.
Which of the following is most closely associated with male pattern alopecia?
A) Absence of a genetic predisposition
B) Decreased activity of 5alpha-reductase within genetically susceptible hair follicles
C) Increased serum level of testosterone
D) Prolonged anagen phase
E) Prolonged telogen phase
Correct answer is E.
Male pattern alopecia is associated with a prolonged telogen, or quiescent, phase of the hair growth cycle. During this phase, the follicle becomes inactive, and active hair growth ceases.
Inheritance is the only known cause of male pattern alopecia. Although hereditary alopecia is controlled by a single, dominant, X-linked autosomal gene, polygenetic modifying factors, such as androgen production and age, affect its expressivity.
Male pattern alopecia can only be triggered by a normal adult male serum androgen level if there is genetic predisposition.
Alopecia results from increased 5alpha-reductase activity within genetically susceptible follicles.
It has not been shown to be associated with increased plasma levels of testosterone.
The anagen phase of the hair cycle, during which hair actively grows, is typically shortened in patients with alopecia.
Alopecia results when which of the following changes in the hair growth cycle occur?
Shortened Prolonged
(A) Anagen phase Catagen phase
(B) Anagen phase Telogen phase
(C) Catagen phase Telogen phase
(D) Telogen phase Anagen phase
(E) Telogen phase Catagen phase
The correct response is Option B.
Balding occurs when the anagen phase is shortened and the telogen phase is prolonged.
Human hair undergoes a normal cycle of growth and rest characterized by three stages: anagen, catagen, and telogen. The anagen (active) phase lasts 1000 days in men and two to five years longer in women. At any one time, 85% to 90% of hairs are in the anagen phase. The catagen (degradation) phase follows anagen and lasts several weeks. During this phase, the follicular bulb atrophies and degrades. After this, the telogen (resting) phase begins and lasts two to four months. At any given time, approximately 10% of hairs are in the telogen phase. On average, 50 to 100 telogen hairs fall out every day and are replaced with new growing hairs. Balding occurs when the anagen (active) phase is shortened and the telogen (resting) phase is prolonged.
Which one of the following statements is correct regarding the blood supply to the scalp?
A) The anterior scalp is supplied by the supraorbital and supratrochlear vessels from the external carotid artery.
B) The supratrochlear vessels are lateral to the supraorbital vessels.
C) The posterior territory is the largest area and is supplied by the occipital vessels.
D) The lesser occipital artery supplies the posterolateral scalp.
E) The lateral territory is supplied by the superficial temporal artery, which arises from theexternal carotid artery.
Convert answer is E.
The lateral territory is supplied by the superficial temporal artery, which arises from the external carotid artery.
The scalp derives its blood supply from both the internal and external carotid systems. It is divided into four zones: anterior, posterior, lateral, and posterolateral. Each zone has its own blood supply, with collateralization between zones. This is clinically relevant with respect to scalp reconstruction using local flaps.
The anterior scalp is supplied by the supraorbital and supratrochlear vessels. These derive from the internal carotid vessels (not the external carotid vessels). The supratrochlear vessels lie medial (not lateral) to the supraorbital vessels.
The posterior territory is supplied by the occipital vessels and perforators from the splenius capitis and trapezius, but it is not the largest territory.
The largest is the lateral territory, which is supplied by the superficial temporal arteries. A lesser occipital artery does not exist. The greater and lesser occipital nerves supply sensation to the occipital territory.
The posterolateral scalp is the smallest territory and is supplied by the posterior auricular artery.
A 65-year-old woman who has undergone multiple resections for recurrent lentigo maligna melanoma with repeated central advancements of the remaining scalp via skin grafting over the past 10 years has frequent irritation of the skin at the grafting sites (image shown). No evidence of further disease has been noted over the past four years. Which of the following is the most appropriate management at this time?
A) Full-thickness skin grafting
B) Micrograft hair transplantation
C) Rerotational flap advancement
D) Staged excision and primary closure
E) Tissue expansion
Correct answer is E.
Because of continued skin breakdown in this area of postsurgical alopecia, tissue expansion followed by adjacent tissue transfer is the most appropriate surgical procedure at this time. This patient has had multiple excisions with repeated advancement followed by skin grafting. The remaining native vessels should be sufficient to supply the expanded scalp skin. Tissue expansion and coverage are usually tolerated well by patients of this age.
Hair transplantation is unlikely to be successful in this patient because of extensive scars in the area. Staged excision of the prior skin grafts and primary closure will not improve this patient’s alopecia and are unlikely to relieve the skin irritation caused by the thinned skin over the calvaria. Because advancement has already been done, little additional advancement can be achieved without back-grafting exposed areas. Full-thickness grafts will not allow sufficient hair growth or replacement.
Male pattern baldness is characterized by which of the following growth phase disturbances?
The correct response is Option A.
Male pattern baldness follows an X-linked dominant inheritance pattern. The anagen phase of hair growth is the active growth phase and lasts approximately 1000 days in men. In the anagen phase, follicular cells are actively multiplying and becoming keratinized. In men with normal hair growth, 85 to 90% of hairs are in this phase, with hair growing 1 cm per month. The catagen phase is known as the transitional or degradation phase and typically lasts 2 to 3 weeks and is characterized by atrophy of the bulb, with keratinization of the hair base, and separation of the hair base from the dermal papilla. The telogen phase of hair growth usually lasts 3 to 4 months and is also known as the resting phase and is characterized by the inactivation of the hair follicle, cessation of hair growth and hair shedding.
In men with normal hair growth, 10% of hair follicles are in the telogen phase, causing approximately 50 to 100 hairs to be shed on average per day. In male pattern baldness there is an increased percentage of hairs in the telogen phase and a decreased percentage of hairs in the anagen phase.
A 44-year-old woman comes to the office for consultation regarding loss of hair on the scalp. Which of the following findings in this patient is LEAST amenable to surgical follicular transplantation?
(A) Alopecia associated with chronic telogen effluvium
(B) Alopecia at the site of surgical scars
(C) Frontal temporal alopecia
(D) Generalized thinning of hair with discrete areas of alopecia
(E) Global diffuse thinning of hair
The correct response is Option A.
Female alopecia differs from male alopecia in that it requires a more in-depth history and workup because of the numerous hormonal and medical causes for hair loss in women.
Alopecia due to hormonal and medical causes, including chronic telogen effluvium (persistent increased telogen hair shedding), is usually not responsive to surgical hair restoration, and such procedures may exacerbate the alopecia.
Patients with global diffuse hair thinning may benefit from surgical restoration; however, in these patients, donor hair tends to be of poor quality.
Generalized hair thinning with discrete areas of alopecia is the most common pattern of hair loss in women and is responsive to surgical restoration. Traumatic or surgical scar alopecia may also respond to surgical restoration.
Women with frontal temporal alopecia may be treated in a similar manner as patients with male pattern hair loss.
In micrografting hair transplantation, which of the following best represents the structure of the transplanted unit?
(A) Isolated hair follicles
(B) Hair follicles with dermal elements
(C) Hair follicles with subcutaneous tissue
(D) Hair follicles with galea
(E) Hair follicles with pericranium
The correct response is Option B.
Hair in healthy scalp grows in one, two, three, or four hairs, each with their own associated neurovascular bundles, sebaceous glands, sweat glands, and piloerectile muscles surrounded by collagen. These €œphysioanatomic € units, when used as micrografts, have been shown to provide excellent results in hair transplantation.
The anatomy of an individual hair follicle includes the dermal papillae bulb, consisting of the dermal and epidermal coat. The dividing cells within the bulb form a cement column of keratinized dead cells held together with a cystine matrix to make the hair shaft.
The macroscopic hair transplantation technique of hair plugs with multiple hair follicles, intervening skin, subcutaneous tissue, epicranial and subepicranial tissue can successfully transplant hair but with an unnatural appearance.
Hair follicles are found in which of the following layers of the scalp?
A) Epidermis
B) Papillary dermis
C) Reticular dermis
D) Subcutaneous layer
Correct answer is D.
The hair follicles are located within the subcutaneous layer of the scalp. Human hair is primarily composed of the keratin protein; the hair shaft is produced by the matrix, which is in turn produced by the follicle. Hair follicles are indentations of the epidermis located within the subcutaneous layer of the scalp. It is important to know the anatomy of the hair follicle in order to successfully harvest and transplant scalp hair, which can be retained with some degree of permanence following transplantation. Because successful punch grafting depends on meticulous technique, the grafts should be harvested at the appropriate depth while avoiding trauma to the hair follicles.
A 7-year-old girl who sustained burns to the head three years ago is scheduled to undergo reconstruction with tissue expansion. Preoperative physical examination shows a 7-14 cm area of alopecia on the scalp and scarring on the forehead. Which of the following is the most appropriate placement of tissue expanders in this patient?
A) Deep to galea and superficial to pericranium
B) Deep to the galea and superficial to the frontalis muscle
C) Deep to the pericranium and deep to the frontalis muscle
D) Deep to the pericranium and superficial to the frontalis muscle
E) Superficial to the galea and deep to the frontalis muscle
Correct answer is A.
To provide the maximal amount of safe expansion, tissue expanders are placed between the galea and periosteum in the scalp and between the frontalis muscle and periosteum in the forehead. Placement of the expander deep to the periosteum would result in difficult, painful, and unpredictable expansion. Placement of the expander superficial to the galea might result in premature extrusion of the device and an unreliable flap after its removal. Expansion of the galea and frontalis is critical in optimizing blood supply to the expanded forehead skin and scalp.
A 41-year-old woman comes to the office for consultation regarding breast reconstruction after mastectomy. She is also embarrassed by her sudden loss of hair as a result of chemotherapy with paclitaxel. All of her hair has fallen out, and she wears a wig. Which of the following is the most likely diagnosis for this patient’s hair loss?
A) Alopecia areata
B) Anagen effluvium
C) Androgenetic alopecia
D) Telogen effluvium
E) Traction alopecia
The correct response is Option B.
Anagen effluvium occurs after an insult to the hair follicle that impairs its mitotic or metabolic activity. This hair loss is commonly associated with chemotherapy. The characteristic finding in anagen effluvium is the tapered fracture of the hair shafts. The hair shaft narrows as a result of damage to the matrix. Eventually, the shaft fractures at the site of narrowing and causes the loss of hair. Hair regrowth occurs after the cessation of chemotherapy.
Androgenetic or androgenic alopecia is caused by the action of androgens. Dihydrotestosterone (DHT) is partially to blame, as it is in men. Androgenic alopecia can be caused by a variety of factors tied to the actions of hormones, including some ovarian cysts, taking high-androgen-index birth control pills, pregnancy, and menopause.
Telogen effluvium is attributable to stress on the body, such as childbirth, malnutrition, severe infection, major surgery, or extreme mental stress. Many of the 90% or so of hairs in the growing (anagen) or transitional (catagen) phases can shift all at once into the resting (telogen) phase. A few weeks to several months after the stressful event, a shedding phenomenon called telogen effluvium begins. It is possible to lose handfuls of hair at a time. This phenomenon is usually self-limited, and hair growth returns.
Alopecia areata is an inflammatory condition thought to result from the immune system attacking the hair follicles at the root. Treatment may include steroids or minoxidil. Hair loss can be temporary or permanent.
Traction alopecia is caused by localized trauma from tight hairstyles, braids, cornrows, etc. If recognized early enough, the hair will grow back.
A 27-year-old man has traumatic absence of the lateral third of the right eyebrow one year after sustaining avulsion and laceration injuries to the forehead and cheek. On current physical examination, there is an avulsion scar in the supraorbital region and a laceration extending from the lateral canthus directly posterior to the temporal scalp, both of which are well healed. The patient would like to undergo reconstruction of the avulsed eyebrow.
Which of the following is the most appropriate reconstructive option?
(A) Composite scalp graft containing hair follicles
(B) Median forehead flap containing hair-bearing tissue from the anterior scalp
(C) Temporal scalp flap based on the ipsilateral superficial temporal artery
(D) Washio flap
(E) Microplug hair transplantation
The correct response is Option A.
In this patient who has absence of the lateral third of the eyebrow resulting from trauma, composite grafting from the scalp is the most appropriate reconstructive option. This technique would be associated with the greatest chance for hair growth in this patient; in addition, the donor scar would be inconspicuous.
Reconstruction with a median forehead flap is a procedure that requires multiple stages and would result in an unsightly donor site scar. Both the temporal scalp flap and Washio flap would be based on the posterior temporal branch of the superficial temporal artery; however, this artery was most likely transected when the patient sustained the facial laceration, eliminating the possibility of using these flaps. Microplug hair transplantation is unreliable over scar tissue, especially traumatized soft tissue and radiated scars.
An otherwise healthy 26-year-old man with a receding hairline presents for hair restoration of the frontal scalp. Which of the following phenomena most accurately describes features associated with this patient’s condition?
A) Absence of vellus hairs
B) Decreased duration of telogen
C) Eosinophilic perifolliculitis
D) Increased duration of anagen
E) Miniaturization of hair follicles
The correct response is Option E.
Male androgenic alopecia is determined by a genetic predisposition. The normal anagen-catagen-telogen cycle is disturbed, and the anagen:telogen ratio is altered. This is due to the lengthening of the telogen denominator in this ratio. Additional aspects include gradual replacement of the normal hair shafts with vellus hair, miniaturization of the hair follicle, and an activated T-cell lymphohistiocytic perifollicular inflammation.
According to the donor dominance concept of hair transplantation, which of the following is the most appropriate donor site?
(A) Frontal scalp
(B) Occipital scalp
(C) Parietal scalp
(D) Sideburn
(E) Vertex
The correct response is Option B.
In order to successfully transplant hair using minigrafting or micrografting techniques, the surgeon must understand the concept of donor dominance, which states that each hair follicle possesses its own individual, genetically-defined lifespan. Because of this, hair follicles located in those areas that tend to have a longer lifespan will continue to possess the same lifespan even after they have been transplanted. The hairs of the occipital scalp have the longest genetically-defined lifespan in most patients; in addition, this donor site is acceptable aesthetically.
Depending on the classification of male-pattern alopecia, early hair loss can occur in the frontal, parietal, or vertex regions. The sideburns often have a lifespan that is genetically similar to the occipital area, but the donor site is quite small and usually unacceptable.
A 55-year-old woman presents with androgenic alopecia. Her husband had a hair transplant 5 years ago. Which of the following characteristics of androgenic alopecia is more common in women than men?
A) More rapidly progressive
B) Not induced by dihydrotestosterone
C) Thinning tends to be frontoparietal
D) Topical minoxidil is ineffective
The correct response is Option C.
Unlike in men, androgenic alopecia in women tends to spare the frontal hairline and tends to affect the frontoparietal scalp. Like in men, it is a chronically progressive disease and causes miniaturization of scalp follicles through exposure of endogenous dihydrotestosterone in patients with increased scalp androgen receptors and 5-reductase concentrations. Topical minoxidil has been shown to increase scalp blood supply and slow hair loss in both males and females.
Which of the following terms represents the primary active phase of hair growth?
(A) Anagen
(B) Anaphase
(C) Metaphase
(D) Telogen
(E) Telophase
The correct response is Option A.
Normal hair growth involves two primary phases. The active phase, anagen, is the phase of hair growth. In this phase, which can last three to five years, approximately 85% of hair follicles produce hair. The resting phase, telogen, heralds the loss of the hair shaft and affects approximately 15% of hair follicles at any given time. Balding occurs when the anagen phase is shortened and the telogen phase is prolonged.
Anaphase, metaphase, and telophase are all phases in cell division and the replication of deoxyribonucleic acid. They are not specifically related to hair growth.
Which one of the following statements is correct regarding scalp innervation
A) The supraorbital nerve has both superficial and deep divisions.
B) The zygomaticofacial nerve is a branch of the ophthalmic division of trigeminal nerve.
C) The auriculotemporal nerve supplies the posterior and lateral scalp.
D) The lesser occipital nerve emerges from the semispinalis muscle, 3 cm below the occipital protuberance.
Correct answer is A.
The supraorbital nerve has superficial and deep divisions. The superficial component supplies sensation to the forehead anterior to the hairline. The deep component supplies sensation posterior to the hairline. This has clinical relevance in brow-lift procedures, bicoronal cranial flaps, and trauma in which the nerves may be damaged, leaving an area of paresthesia.
The zygomaticofacial nerve derives from the maxillary division (not the ophthalmic division) of the trigeminal nerve. It supplies a region of skin lateral to the brow.
The auriculotemporal nerve derives from the mandibular division of the trigeminal nerve and supplies the lateral scalp.
The greater and lesser occipital nerves supply the occipital territory, but it is the greater occipital nerve that emerges from the semispinalis 3 cm below the occipital protuberance.
The facial nerve supplies the scalp muscles.
The trigeminal nerve supplies the muscles of mastication and the tensor tympani.
A 35-year-old woman with diffuse hair thinning comes to the office for evaluation of hair transplantation. Physical examination shows facial hirsutism, acne, and diffusely decreased hair density over the crown and frontal scalp, except for the frontal hairline, which is quite well preserved. The scalp skin appears normal. Which of the following is the most likely underlying cause?
A ) Alopecia totalis
B ) Polycystic ovary syndrome
C ) Psoriasis
D ) Tinea capitis
E ) Trichotillomania
The correct response is Option B.
Although all options listed can cause hair loss, psoriasis and tinea capitis would be associated with visible scalp changes, such as scaling or crusting. Trichotillomania, which is traction alopecia from compulsive hair pulling, would be unlikely to show a diffuse hair loss with sparing of the frontal hairline. Alopecia totalis, by definition, is total hair loss over the entire scalp, and does not fit the patient’s description.
This woman has female pattern hair loss (FPHL), which is the preferred term for androgenetic alopecia in females. Typically there is a reduction in hair density over the crown and frontal scalp, with relative sparing and preservation of the frontal hairline, as described for this patient. Between 10 and 40% of women with FPHL have been found to be hyperandrogenic. The presence of menstrual irregularities, marked acne, or hirsutism in this patient should prompt an investigation for polycystic ovary syndrome or other underlying causes.
A 4-year-old patient with a full head of hair requires reconstruction of a congenital nevus to the vertex of the scalp. The lesion covers 30% of the scalp. Which one of the following is the best reconstructive option?
A) Serial excision and direct closure
B) Tissue expansion and local flap reconstruction
C) Transposition flap and skin graft to the donor site
D) Orticochea flaps with galeal scoring
E) Free tissue muscle transfer and split-skin graft
Correct answer is B.
The primary aim in this case is to fully remove the nevus and provide soft tissue cover while retaining a full head of hair. Two approaches to the management of congenital nevi on the scalp are serial excision or excision and tissue expansion. Serial excision is best suited to smaller defects that can be excised within three or four sessions. A defect of 30% is best treated with tissue expansion and local flap closure. Defects up to 50% of the hair-bearing scalp can be closed with tissue expansion and avoid bald patches. A transposition flap and skin graft would create a large bald area and would not be aesthetically pleasing. Free tissue transfer would be reserved for near-total scalp defects, particularly where bone is exposed. The Orticochea flap is not well suited to vertex defects because the location does not allow a large third flap to cover the donor defect.
Which of the following best characterizes male-pattern alopecia?
The correct response is Option B.
Male-pattern alopecia is characterized by a decrease in the anagen, or active, phase of the hair follicle and an increase in the telogen, or resting, phase. Patients with this condition have more of their hair follicles in the resting phase, and those in the active phase produce hair growth for a shorter time. Hair follicles can also be classified as either terminal, which produce larger, pigmented fibers, or villous, which produce finer fibers that have less pigmentation and are more difficult to visualize. Terminal fibers are found typically on the adult scalp, eyebrows, axilla, and pubic region, while villous fibers are noted on the forehead, bald scalp, and along the hairline itself. In patients with male-pattern alopecia, many follicles in the scalp are transformed from terminal to villous.
Minoxidil is the recommended treatment of male-pattern alopecia. This agent halts the hair loss and increases the number of hairs as well as the diameter of the existing hairs, but is only effective in patients with mild to moderate baldness.
A 19-year-old man who sustained burns to 40% of the total body surface area at 4 years of age comes to the burn clinic for consultation regarding correction of the scalp defect shown. Physical examination shows patchy alopecia of the temporal scalp and hypertrophic scarring. Which of the following is the most appropriate surgical procedure for reconstruction of this patient’s scalp?
A) Hair transplantation with micrografts and minigrafts
B) Orticochea flap
C) Serial excision and closure
D) Temporoparietooccipital (Juri) flap
E) Tissue expansion
Correct answer is E.
The patient shown has a large (>25 cm2) parietal scalp defect that resulted from a flame burn. It is clear that hair transplantation has already been attempted with minimal take and coverage. Hair transplantation with micrografts and minigrafts is a technique that has been described to treat large areas of burn alopecia. However, it is usually reserved for smaller areas, or as a revisional procedure to camouflage incisions that result from rotational flaps.
Tissue expansion is the preferred method for secondary reconstruction of a large parietal scalp defect. Approximately 50% of scalp can be reconstructed with expanded scalp tissue, although this may require multiple stages. Expander complication rates may be as high as 25% and may include infection, exposure, extrusion, and device failure. Scalp expansion in children is difficult. There is a higher incidence of infection and decreased tolerance of pain. Moreover, there is a risk of skull deformation after a prolonged period of expansion. Therefore, deferral until the patient reaches young adulthood is reasonable.
A 70-year-old man comes to the office because of a 6-month history of a wound in the right supraorbital region that is draining fluid. Photographs are shown. History includes type 1 diabetes mellitus, chronic obstructive pulmonary disease, and basal and squamous cell carcinoma in the supraorbital area, which was treated with Mohs micrographic surgery, cranial burring, split-thickness skin grafting, and radiation. He has smoked one pack of cigarettes daily for 60 years. Physical examination shows a 4 × 2-cm area of exposed bone with no mobility in the immediately adjacent skin. Echocardiography shows an ejection fraction of 25%. Examination of a specimen obtained on biopsy shows recurrence of squamous cell carcinoma. After excising the tumor, a bony deformity of the supraorbital rim and exposed dura are present. Which of the following is most appropriate to correct this patient’s defect?
A) Alloplastic reconstruction and a local flap
B) Rib graft with local soft-tissue coverage
C) Scalp flap
D) Skin graft
Correct answer is C.
In the scenario described, bony reconstruction will not impact function, and therefore soft-tissue coverage is adequate. A scalp flap is the most appropriate option because it will bring in blood supply and soft-tissue coverage without the risks associated with extended general anesthesia.
Skin grafting would likely not heal in a radiated bed. The long history of a draining wound is a contraindication to the use of alloplastic material. Although a rib graft would provide bony support, it would also increase risk because of the donor site morbidity in the patient described, who has chronic obstructive pulmonary disease and is at high risk for postoperative pneumonia.
