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Complex oncologic resection and reconstruction of the scalp: Predictors of morbidity and mortality

  • Tecce, Michael G. (Division of Plastic Surgery, Department of Surgery, University of Pennsylvania) ;
  • Othman, Sammy (Division of Plastic Surgery, Department of Surgery, University of Pennsylvania) ;
  • Mauch, Jaclyn T. (Division of Plastic Surgery, Department of Surgery, University of Pennsylvania) ;
  • Nathan, Shelby (Division of Plastic Surgery, Department of Surgery, University of Pennsylvania) ;
  • Tilahun, Estifanos (Division of Plastic Surgery, Department of Surgery, University of Pennsylvania) ;
  • Broach, Robyn B. (Division of Plastic Surgery, Department of Surgery, University of Pennsylvania) ;
  • Azoury, Said C. (Division of Plastic Surgery, Department of Surgery, University of Pennsylvania) ;
  • Kovach, Stephen J. (Division of Plastic Surgery, Department of Surgery, University of Pennsylvania)
  • Received : 2020.05.23
  • Accepted : 2020.08.18
  • Published : 2020.08.20

Abstract

Background: Oncologic resection of the scalp confers several obstacles to the reconstructive surgeon dependent upon patient-specific and wound-specific factors. We aim to describe our experiences with various reconstructive methods, and delineate risk factors for coverage failure and complications in the setting of scalp reconstruction. Methods: A retrospective chart review was conducted, examining patients who underwent resection of fungating scalp tumors with subsequent soft-tissue reconstruction from 2003 to 2019. Patient demographics, wound and oncologic characteristics, treatment modalities, and outcomes were recorded and analyzed. Results: A total of 189 patients were appropriate for inclusion, undergoing a range of reconstructive methods from skin grafting to free flaps. Thirty-three patients (17.5%) underwent preoperative radiation. In all, 48 patients (25.4%) suffered wound site complications, 25 (13.2%) underwent reoperation, and 47 (24.9%) suffered from mortality. Preoperative radiation therapy was an independent risk factor for wound complications (odds ratio [OR], 2.85; 95% confidence interval [CI], 1.1-7.3; p=0.028) and reoperations (OR, 4.45; 95% CI, 1.5-13.2; p=0.007). Similarly, the presence of an underlying titanium mesh was an independent predictor of wound complications (OR, 2.49; 95% CI, 1.1-5.6; p=0.029) and reoperations (OR, 3.40; 95% CI, 1.2-9.7; p=0.020). Both immunosuppressed status (OR, 2.88; 95% CI, 1.2-7.1; p=0.021) and preoperative radiation therapy (OR, 3.34; 95% CI, 1.2-9.7; p=0.022) were risk factors for mortality. Conclusion: Both preoperative radiation and the presence of underlying titanium mesh are independent risk factors for wound site complications and increased reoperation rates following oncologic resection and reconstruction of the scalp. Additionally, preoperative radiation, along with an immunosuppressed state, may predict patient mortality following scalp resection and reconstruction.

References

  1. Steiner D, Horch RE, Eyupoglu I, Buchfelder M, Arkudas A, Schmitz M, et al. Reconstruction of composite defects of the scalp and neurocranium: a treatment algorithm from local flaps to combined AV loop free flap reconstruction. World J Surg Oncol 2018;16:217.
  2. Ibrahim Z, Santiago GF, Huang J, Manson PN, Gordon CR. Algorithmic approach to overcome scalp deficiency in the setting of secondary cranial reconstruction. J Craniofac Surg 2016;27:229-33.
  3. Desai SC, Sand JP, Sharon JD, Branham G, Nussenbaum B. Scalp reconstruction: an algorithmic approach and systematic review. JAMA Facial Plast Surg 2015;17:56-66.
  4. Fischer JP, Sieber B, Nelson JA, Kovach SJ, Taylor JA, Serletti JM, et al. A 15-year experience of complex scalp reconstruction using free tissue transfer-analysis of risk factors for complications. J Reconstr Microsurg 2013;29:89-97.
  5. Chao AH, Yu P, Skoracki RJ, Demonte F, Hanasono MM. Microsurgical reconstruction of composite scalp and calvarial defects in patients with cancer: a 10-year experience. Head Neck 2012;34:1759-64.
  6. Swetter SM, Tsao H, Bichakjian CK, Curiel-Lewandrowski C, Elder DE, Gershenwald JE, et al. Guidelines of care for the management of primary cutaneous melanoma. J Am Acad Dermatol 2019;80:208-50.
  7. Work Group; Invited Reviewers, Kim JYS, Kozlow JH, Mittal B, Moyer J, et al. Guidelines of care for the management of cutaneous squamous cell carcinoma. J Am Acad Dermatol 2018;78:560-78.
  8. Work Group; Invited Reviewers, Kim JYS, Kozlow JH, Mittal B, Moyer J, et al. Guidelines of care for the management of basal cell carcinoma. J Am Acad Dermatol 2018;78:540-59.
  9. Newman MI, Hanasono MM, Disa JJ, Cordeiro PG, Mehrara BJ. Scalp reconstruction: a 15-year experience. Ann Plast Surg 2004;52:501-6.
  10. Janus JR, Peck BW, Tombers NM, Price DL, Moore EJ. Complications after oncologic scalp reconstruction: a 139-patient series and treatment algorithm. Laryngoscope 2015;125:582-8.
  11. Goessler UR, Bugert P, Kassner S, Stern-Straeter J, Bran G, Sadick H, et al. In vitro analysis of radiation-induced dermal wounds. Otolaryngol Head Neck Surg 2010;142:845-50.
  12. Haubner F, Ohmann E, Pohl F, Strutz J, Gassner HG. Wound healing after radiation therapy: review of the literature. Radiat Oncol 2012;7:162.
  13. Jasper KD, Holloway CL, DeVries KJ, Truong PT. Local relapse and survival outcomes in patients with scalp sarcoma: a retrospective study of 95 patients treated in a provincial cancer care institution over 25 years. Cureus 2019;11:e5236.
  14. Ihara H, Kaji T, Katsui K, Miyake T, Waki T, Katayama N, et al. Single institutional experience of radiation therapy for angiosarcoma of the scalp without cervical lymph node metastases: Impact of concurrent chemoradiation with maintenance chemotherapy using taxanes on patient prognosis. Mol Clin Oncol 2019;11:498-504.
  15. Hata M, Wada H, Ogino I, Omura M, Koike I, Tayama Y, et al. Radiation therapy for angiosarcoma of the scalp: treatment outcomes of total scalp irradiation with X-rays and electrons. Strahlenther Onkol 2014;190:899-904.
  16. Shin JY, Roh SG, Lee NH, Yang KM. Predisposing factors for poor prognosis of angiosarcoma of the scalp and face: systematic review and meta-analysis. Head Neck 2017;39:380-6.
  17. Terakedis BE, Anker CJ, Leachman SA, Andtbacka RH, Bowen GM, Sause WT, et al. Patterns of failure and predictors of outcome in cutaneous malignant melanoma of the scalp. J Am Acad Dermatol 2014;70:435-42.
  18. Xie C, Pan Y, McLean C, Mar V, Wolfe R, Kelly J. Impact of scalp location on survival in head and neck melanoma: a retrospective cohort study. J Am Acad Dermatol 2017;76:494-8.
  19. Dundar Y, Cannon RB, Hunt JP, Monroe M, Suneja G, Hitchcock YJ. Radiotherapy regimens in patients with nonmelanoma head and neck skin cancers. Int J Dermatol 2018;57:441-8.
  20. Harwood AR, Lawson VG. Radiation therapy for melanomas of the head and neck. Head Neck Surg 1982;4:468-74.
  21. Wang HT, Erdmann D, Olbrich KC, Friedman AH, Levin LS, Zenn MR. Free flap reconstruction of the scalp and calvaria of major neurosurgical resections in cancer patients: lessons learned closing large, difficult wounds of the dura and skull. Plast Reconstr Surg 2007;119:865-72.
  22. Stucker F, Ackermann D. Immunosuppressive drugs - how they work, their side effects and interactions. Ther Umsch 2011;68:679-86.
  23. Boots JM, Christiaans MH, van Hooff JP. Effect of immunosuppressive agents on long-term survival of renal transplant recipients: focus on the cardiovascular risk. Drugs 2004;64:2047-73.
  24. Eckardt A, Fokas K. Microsurgical reconstruction in the head and neck region: an 18-year experience with 500 consecutive cases. J Craniomaxillofac Surg 2003;31:197-201.
  25. Cabraja M, Klein M, Lehmann TN. Long-term results following titanium cranioplasty of large skull defects. Neurosurg Focus 2009;26:E10.
  26. Lee EI, Chao AH, Skoracki RJ, Yu P, DeMonte F, Hanasono MM. Outcomes of calvarial reconstruction in cancer patients. Plast Reconstr Surg 2014;133:675-82.
  27. Maqbool T, Binhammer A, Binhammer P, Antonyshyn OM. Risk factors for titanium mesh implant exposure following cranioplasty. J Craniofac Surg 2018;29:1181-6.
  28. Kwiecien GJ, Rueda S, Couto RA, Hashem A, Nagel S, Schwarz GS, et al. Long-term outcomes of cranioplasty: titanium mesh is not a long-term solution in high-risk patients. Ann Plast Surg 2018;81:416-22.
  29. Othman S, Azoury SC, Tecce MG, Shakir S, Rios-Diaz AJ, Mauch JT, et al. Free flap reconstruction of complex oncologic scalp defects in the setting of mesh cranioplasty: risk factors and outcomes. J Craniofac Surg 2020;31:1107-10.
  30. Oliver JD, Banuelos J, Abu-Ghname A, Vyas KS, Sharaf B. Alloplastic cranioplasty reconstruction: a systematic review comparing outcomes with titanium mesh, polymethyl methacrylate, polyether ether ketone, and Norian implants in 3591 adult patients. Ann Plast Surg 2019;82(5S Suppl 4):S289-4.
  31. Goiato MC, Anchieta RB, Pita MS, dos Santos DM. Reconstruction of skull defects: currently available materials. J Craniofac Surg 2009;20:1512-8.