title: Algorithmic Approach to Overcome Scalp Deficiency in the Setting of Secondary Cranial Reconstruction.
abstract: BACKGROUND
  Multidisciplinary approaches have shown improved outcomes in secondary cranial reconstruction, however, scalp deficiency remains a common obstacle for tension-free scalp closure during cranioplasty. Therefore, our objective was to create an algorithmic approach using a novel concept of "component separation" to help minimize potential complications.
  
  
  METHODS
  The authors tested the hypothesis of achieving greater scalp mobility by way of "component separation" in a half-scalp, bilateral cadaver study, and describe within 2 clinical examples. Pterional-sized (N = 2) and hemicraniectomy-sized (N = 2) scalp flaps were dissected on 2 cadaveric heads using an internal control for each scenario. All flaps (N = 4) were created with (experimental group) and without (control group) "retaining ligament release." Total amounts of scalp mobility were measured bilaterally and compared accordingly.
  
  
  RESULTS
  Scalp flap mobility was calculated from the sagittal midline using identical arcs of rotation. With zero tension, we observed an increased distance of movement equaling 1 cm for the "experimental" pterional flap, compared with the contralateral "control." Similarly, we found an increase of additional 2 cm in scalp mobility for the "experimental" hemicraniectomy-sized flap.
  
  
  CONCLUSIONS
  Tension free scalp closure is most critical for achieving improved outcomes in secondary cranial reconstruction. In this study, we show that a range of 1 to 2 additional centimeters may be gained through a component separation, which is of critical value during scalp closure following cranioplasty. Therefore, based on our high volume cranioplasty experience and cadaver study presented, we offer some new insight on methods to overcome scalp deficiency accompanying secondary cranial reconstruction.
authors.affiliation: *Department of Plastic & Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore †Department of Otolaryngology-Head & Neck Surgery, Walter Reed National Military Medical Center, Bethesda ‡Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD.
authors.forename: Zuhaib
authors.initials: Z
authors.lastname: Ibrahim
authors.forename: Gabriel F
authors.initials: GF
authors.lastname: Santiago
authors.forename: Judy
authors.initials: J
authors.lastname: Huang
authors.forename: Paul N
authors.initials: PN
authors.lastname: Manson
authors.forename: Chad R
authors.initials: CR
authors.lastname: Gordon
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000465:Algorithms; D001672:Biocompatible Materials / Q000737:chemistry; D018786:Bone Substitutes / Q000737:chemistry; D002545:Brain Ischemia / Q000601:surgery; D002102:Cadaver; D002280:Basal Cell Carcinoma / Q000601:surgery; D003399:Craniotomy / Q000295:instrumentation / Q000379:methods*; D056424:Decompressive Craniectomy / Q000379:methods; D005205:Fascia / Q000033:anatomy & histology / Q000637:transplantation; D006258:Head and Neck Neoplasms / Q000601:surgery; D006801:Humans; D008022:Ligaments / Q000033:anatomy & histology; D008297:Male; D019904:Polymethyl Methacrylate / Q000737:chemistry; D019651:Plastic Surgery Procedures / Q000295:instrumentation / Q000379:methods*; D012399:Rotation; D012535:Scalp / Q000033:anatomy & histology / Q000098:blood supply / Q000601:surgery*; D012878:Skin Neoplasms / Q000601:surgery; D016038:Skin Transplantation / Q000379:methods; D020521:Stroke / Q000601:surgery; D013524:Surgical Flaps / Q000601:surgery*
chemical_list: D001672:Biocompatible Materials; D018786:Bone Substitutes; D019904:Polymethyl Methacrylate