الفهرس 
Anatomy of the scalpOnly 14 pages are availabe for public view
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Abstract
Scalp reconstruction is a “continuous challenge” for the usual activity of the plastic surgeon due to searching for an option which provides a good aesthetic outcome as well as durable coverage.
Knowledge of the anatomy of the scalp and forehead will assist the reconstructive surgeon in the choice of local flap options as well as choosing a potential microsurgical recipient vessels site if needed.
Scalp defects are due to several causes such as trauma (mechanical, thermal, chemical), tumor resection, congenital anomalies (aplasia cutis, vascular malformations, and nevus), inflammation, radiation, and chemotherapy.
There are many surgical methods for reconstruction of the scalp e.g primary closure, secondary intention, skin graft, local flaps, distant flaps, and free tissue transfer. Also there are other recent procedures that may be used such as tissue expansion, artificial dermis then skin graft and surgical hair transplantation.
As the type of surgical procedure depends on the size, location and the depth of the defect, Primary closure is suitable for small defects (< 3cm). Secondary intention is useful in patients (smokers, patients who have a history of local radiation) whom condition will interfere with the success of flaps or grafting. Skin graft has a role in temporary covering of the defects until healing occurs then definite treatment is done.
Flaps are the most used options when reconstructing the scalp. They are classified into: local, distant, and free. Local flaps are more commonly used for reconstruction. There are different types of local flaps used e.g single or multiple rotation advancement flaps, VY or H-shaped advancement flaps, transposition flaps, bilobed flaps. They are used for small to moderate-sized defects.
Distant flaps like trapezius muscle and latissimus dorsi muscle flap may be alternative option when large defect (>25 cm2), exists. They can cover large defects especially in the occipital region.
Free tissue transfer offers a one-step solution for resurfacing large scalp defects especially if more than 120 cm2 and produces surprisingly good results, especially in patients with preexisting alopecia. The flaps most commonly used for scalp and forehead reconstruction are the anterolateral thigh (ALT) flap, the latissimus dorsi muscle flap, and the radial forearm flap.
Options for treating total scalp avulsion depends on presence of avulsed scalp and its condition (healthy or necrotic), presence of intact periosteum. These options are: if the avulsed scalp is healthy then microvascular anastomosis is done, if not and intact periosteum then grafting, if not free tissue transfer.
Tissue expansion is a validated, reliable, and safe technique used in sec¬ondary reconstruction in scalp reconstruction. It provides broad tissue while preserving the sensitivity, color, and thickness of the scalp and hair. Many patients may not agree to perform tissue expansion because of discomfort, the frequent office visits, the time required for expansion.
Artificial dermis is used to provide a durable coverage, thicker than direct skin grafting on the skull or on granulation tissue in elderly patients that could not tolerate complex reconstructive procedures but there are some limits for using it as prolonged period of local wound management for several weeks prior to skin grafting and its high cost.
Surgical hair transplantation requires stable and vascular recipient site so it should be rarely used acutely in the management of a scalp defect. They are planned as a secondary procedure as wounds that have healed contain hair. It is done by harvesting hair from a donor site into the planed site for hair transplantation.
The goals of calvarial reconstruction are coverage and protection of the intracranial contents. In addition, frontal and temporal defects are noticeable, and the reconstruction should provide restoration of a natural contour. Materials that are used in cranioplasty include; nonvascularized autogenous bone grafts (calvarial, split rib, or iliac crest), vascularized autogenous bone grafts, and alloplastic materials (methylmethacrylate, calcium phosphate cements, and titanium).
In conclusion; successful reconstruction of the scalp with restoration of anterior hair line requires deep knowledge of patient’s clinical condition, precise intraoperative execution, adequate debridement, preservation of blood supply, and proper wound drainage. To achieve this careful preoperative planning is mandatory as each defect has its characteristics which affect choosing the procedure suitable for this defect.