Holcombe, Travis C.

Radiated chronic scalp wounds with exposed bone present a significant reconstructive challenge, particularly when prior attempts have failed or when further surgery is contraindicated due to patient comorbidities or preference. We retrospectively reviewed 10 patients (2014–2024) with radiated chronic scalp wounds with exposed bone who have either failed prior reconstruction, could not medically tolerate anesthesia, or declined surgery. Patients performed daily cleansing with soap and water followed by application of Aquaphor and Silvadene. Treatment duration ranged from 1 to 73 months (mean: 29.4 mo). The area of exposed bone decreased in 6 patients (60%), remained stable in 1 (10%), and increased in 3 (30%). Three of 7 patients with wound improvement (30%) achieved complete healing. Two of 3 patients with wound progression deceased of unrelated causes. To our knowledge, no major complications occurred. These findings support wound care as a safe, and often effective, treatment when larger reconstruction is not feasible.

Syndrome of the Trephined (SoT), also known as sunken or sinking skin flap syndrome (SSFS), is a rare sequela of decompressive craniectomy caused by an atmospheric pressure gradient over the underlying brain parenchyma following bone flap removal. Cranioplasty is the definitive treatment of SoT, although some patients are not surgical candidates or require bridging to definitive treatment. This systematic review identified 7 articles describing nonsurgical interventions for patients with SoT. Three treatment modalities emerged: external orthotics, scalp traction, and Trendelenburg positioning. These approaches demonstrated rapid improvements in neurological symptoms, including restored motor function, improved cognition, resolution of midline shifts, and, in some cases, re-expanded brain parenchyma. While these results are limited to case reports and small case series, they demonstrate promising early outcomes for the noninvasive management of Syndrome of the Trephined.

Introduction: Nonmelanoma skin cancer is the most common malignancy of the scalp. Of these, squamous cell carcinoma (SCC) is the most troublesome. It poses a challenge to the surgeons caring for these patients as the anatomy of the scalp makes excision and reconstruction difficult. Although more superficial lesions are amenable to Mohs micrographic surgery, more invasive lesions require a different approach. This manuscript is a retrospective review of outer table resection for SCC of the scalp invading to the depth of the pericranium. We include a discussion of full thickness craniectomy for invasive SCC, regardless of depth of invasion, for completeness. Methods: IRB approval was obtained from St. Joseph’s Hospital and Medical Center in Phoenix, Arizona. One hundred four potential cases identified based on ICD codes. Ultimately, 23 cases met study criteria and were included in this analysis. Seventeen cases of outer table resection and 6 cases of full craniectomy were discussed. Additionally, the authors’ approach for resection and reconstruction is articulated. Results: Seventeen patients underwent outer table resection at an average age of 79.3 years. All had invasion of the pericranium with a mean surface area of 42.6 cm2. Eight patients had prior radiation treatment for SCC of the scalp and 12 patients had at least 1 prior surgery to attempt excision of their lesions. Two patients had local recurrence for a local control rate of 88.2% (15/17). One patient with metastasis prior to presentation, died 6 months after his initial surgery for disease-free survival rate of 94.1% (16/17) at a mean of 15.4months. Thirteen patients were able to achieve immediate reconstruction with local flaps with or without additional skin grafting (76.5%). Discussion: The data in this study supports that in instances of locally invasive primary SCC of the scalp that extends to the pericranium, excision down to the calvarium with complete circumferential and deep peripheral margin assessment, followed by resection of the outer table, is an excellent option. The low rate of local recurrence and high disease-free survival in this study support that this method allows for optimal oncologic outcome while mitigating the significant morbidity associated with the alternative option of a full thickness craniectomy.

SUMMARY This article describes a unique approach for reconstruction of large helical rim defects. By raising bilateral chondrocutaneous flaps of the helical rim while including a semicircular chondrocutaneous excision of the adjacent scapha and antihelix, large defects can be repaired with minimal loss to the overall external ear circumference. This is a technically simple and reliable method that has resulted in excellent cosmetic outcomes and minimal morbidity in our practice.