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Article

Lessons Learned in Scalp Reconstruction and Tailoring Free Tissue Transfer in the Elderly: A Case Series and Literature Review

by
Michael Sosin
1,
Arif Chaudhry
1,
Carla De La Cruz
1,
Branko Bojovic
1,
Paul N. Manson
2 and
Eduardo D. Rodriguez
3,*
1
Division of Plastic, Reconstructive, and Maxillofacial Surgery, R. Adams Cowley Shock Trauma Center, Baltimore, MD, USA
2
Department of Plastic Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
3
Department of Plastic Surgery, New York University Langone Medical Center, Institute of Reconstructive Plastic Surgery, New York, NY 10012, USA
*
Author to whom correspondence should be addressed.
Craniomaxillofac. Trauma Reconstr. 2015, 8(3), 179-189; https://doi.org/10.1055/s-0034-1393725
Submission received: 6 November 2013 / Revised: 12 February 2014 / Accepted: 12 February 2014 / Published: 24 November 2014
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Versions Notes

Abstract

:
This article aims to demonstrate an individualized approach to an elderly patient requiring scalp reconstruction, to describe the methodology in flap selection, lessons learned, and report outcomes. A retrospective review of a single surgeon’s experience of scalp reconstruction (E. D. R.) using free tissue transfer from 2005 to 2011, in patients older than 70 years, was completed. A total of eight patients met the inclusion criteria, five males and three females, with a mean age of 80.4 years (range, 73–92). Free tissue transfer achieved 100% soft tissue coverage. Six of the eight patients required cranioplasty. The mean size calvarial defect was 92 cm2 (range, 35–285 cm2). The mean flap size was 117.6 cm2 (range, 42–285 cm2). Free flaps included three ulnar, three anterolateral thigh, one latissimus dorsi, and one thoracodorsal perforator flap. The mean follow-up time was 18.4 months (range, 3–46 months). Donor site morbidity was minimal. Mortality was 0%. Immediate flap failure was 0%. Other complications occurred in six of the eight patients. Mean revisionary procedures were 1.25 procedures per patient. It was concluded that chronological age does not increase mortality or catastrophic flap complications; however, morbidity is increased in the elderly and revisionary surgery is likely.

Scalp and calvarial defects are often the result of invasive cutaneous malignancies, osteoradionecrosis, infection, or trauma [1,2]. Treatment of smaller defects involves primary repair and may require undermining adjacent tissue. Local flaps [3,4,5,6] and skin grafts [5,6,7,8] are often implemented early in reconstruction. Positive margins, recurrence of a lesion, chronic wounds from radiation or infection, and failed local flaps can extend the area of excision and result in unsightly defects. Defects are often subject to multiple resections that may result in exposure of underlying vital structures and require coverage (Figure 1). Larger defects, especially those with exposed prosthetic material, calvarium, dura, or brain require free tissue transfer.
In the United States, the population of those 65 years and older, termed “aged,” comprise 13% of the total population amounting to 40.3 million people [9]. In the past decade, the population growth rate of 65 to 74, 75 to 84, 85 to 94, and 94 years and older increased by 18.1, 5.7, 29.9, and 25.9%, respectively [9]. The incidence of cutaneous malignancies of the head and neck is greater in patients aged 80 and older as compared with patients younger than 80 years [10]. This inevitably has and will lead to more operative procedures in elderly patients [11].
Although, free tissue transfer in the elderly is associated with a 5.4 to 9.1% mortality rate, these rates were reported over a quarter century ago [12,13]. Recently, Howard et al. reported similar mortality rates with complication rates as high as 59.3% [14]. These statistics may appropriately lead to trepidation and a guarded approach to more complex rungs of the reconstructive ladder in the elderly [15]. However, with individualization, acceptable morbidity and mortality rates can be obtained. With a combination of advances in microsurgery and improved anesthetic and intensive care, recent studies boast a 0 to 6% mortality rate and a complication rate of 9 to 33% [7,16,17,18,19,20].
When faced with a septua-, octo-, or nonagenarian population, a reconstructive algorithm may be unclear, and the initial candidacy for reconstruction is often the patient’s risk of tolerating general anesthesia. In patients undergoing microsurgical free flaps, age and American Society of Anesthesiology (ASA) risk score were not found to correlate with one another [20,21]. However, when age is corrected for ASA and medical comorbidities, it has been shown to correlate with complications and mortality rates [14,20,21,22,23,24,25]. Specific to geriatric literature, chronological age is not a predictive method of risk assessment of aged patients requiring surgical intervention [26]. Once a patient is deemed a candidate for surgical intervention, the duration of surgery should not be a benchmark in minimizing morbidity. Jones et al. found that neither age nor prolonged operative time was a predictor of medical complications in the microsurgical free tissue transfer of head and neck pathology [21]. Nevertheless, multiple reports encourage a one-staged procedure by using a two-team approach, which can save the patient time, stress, and multiple surgical procedures [7,18,27]. The option of providing the standard of care in the elderly population with free tissue transfer improves quality of life and survival comparable to younger patients [28,29].
The anterolateral thigh (ALT) and latissimus dorsi flaps are reliable and frequently used in scalp and calvarial reconstruction [7,19,30]. The thoracodorsal artery perforator flap is also described in achieving a muscle-preserving procedure [19,31]. This case series presents eight elderly patients with varying comorbidities, excellent mental health, all of whom live independently. All were deemed suitable candidates for free tissue transfer. The algorithm in choosing a flap must not solely rely on flap viability, but equally important is the donor site morbidity. The importance of tailoring scalp and calvarial reconstruction to the patient rather than just their chronological age is stressed after reviewing selected cases from our series of patients. This series also provides longterm expectations that the microsurgeon can expect when managing elderly patients that receive free tissue transfer for scalp reconstruction.

Methods

After receiving institutional review board approval, a single surgeon’s experience of scalp reconstruction (E. D. R.) from 2005 to 2011 in patients older than 70 years was reviewed. A total of eight patients met the inclusion criteria, with a mean age of 80.4 years (range, 73–92) and mean follow-up time of 18.4 months (range, 3–46). Radiation exposure, comorbidities, etiology of scalp defect, location of the defect, calvarial size defect, material used for cranioplasty, flap choice, flap size, site of anastomosis, complications, and follow-up times were recorded. Three cases are described to deliver the salient lessons learned from this case series.

Results

Details of the results are represented in Table 1 and Table 2, with three selected case descriptions provided below (cases 1–3). A total of eight patients met inclusion criteria, five males and three females, with a mean age of 80.4 years (range, 73–92). Free tissue transfer achieved 100% ultimate soft tissue coverage. Cutaneous neoplasms were the inciting etiology of defects in seven of the eight patients, nonhealing wounds were present in five of the eight patients, and exposed bone or prosthetic cranioplasty material was present in four of the eight patients. Radiation exposure occurred in two of the eight patients before free tissue transfer. Six of the eight patients required cranioplasty, all of whom were reconstructed with a titanium prosthetic material. The mean size calvarial defect was 92 cm2 (range, 35–285 cm2). Free flap donor sites include, three ulnar adipocutaneous, one ALT adipocutaneous, one ALT musculocutaneous, one musclesparing thoracodorsal perforator adipocutaneous, and one latissimus dorsi muscle only flap. Mean follow-up time of 18.4 months (range, 3–46). Donor site morbidity was minimal with three of the eight patients requiring a full-thickness skin graft (FTSG) and five of the eight patients were closed primarily. Mean flap size was 117.6 cm2 (range, 42–285). The mean ASA score was 2.75 (range, 2–3). Mortality was 0%. Immediate flap failure due to venous thrombosis or arterial insufficiency was 0%. Other complications included venous congestion, flap atrophy, and dehiscence occurring in four of the eight patients. Atrophy occurred in two patients (muscleonly flap and ulnar adipocutaneous flap) with impending cranioplasty material exposure in one patient requiring a new free flap. Mean revisionary procedures per patient were 1.25 procedures per patient. Ultimately, six different free flaps were utilized in treating eight different patients.

Cases

Case 1

An 87-year-old male patient was referred to our clinic for evaluation of a chronic open wound of the central frontoparietal scalp (Figure 2a). The patient had prior scalp radiation exposure and undergone multiple scalp excisions for recurrent basal cell carcinoma. After a recent fall the patient developed a subdural hematoma requiring craniotomy via a burr hole for evacuation. A 10 × 8 cm scar with exposed parietal bone was visualized at the scalp vertex. The surrounding skin and subcutaneous tissue of the wound were erythematous and attenuated with telangiectatic changes. Of note, the patient was cardiovascularly active on a daily basis and was an avid tennis enthusiast. Wide excision of the chronic wound revealed a full-thickness osteonecrotic calvarium necessitated resection ultimately exposing dura (Figure 2b). The titanium prosthetic cranioplasty material was inset into the 10 × 9 cm boney defect (Figure 2c), and a microsurgical free tissue transfer was completed using a muscle-sparing thoracodorsal artery perforator flap. End-to-end microsurgical anastomoses were completed to the left superficial temporal vessels. Flap measurement was 10 × 9 cm (Figure 3). The donor site was closed primarily. A 12-month follow-up demonstrated excellent flap function (Figure 4) with preserved ambulation in an otherwise active and independent octogenarian. No donor site morbidity was observed.

Case 2

A 92-year-old male patient developed a recurrence of basal cell carcinoma invading the calvarium over the left temporoparietal scalp. The patient had undergone wide local excision, craniectomy, and cranioplasty utilizing methylmethacrylate for coverage of exposed dura. An advancement flap and split-thickness skin graft (STSG) subsequently failed to achieve coverage. The final pathology revealed positive margins with invasion into bone. At this point, the patient was referred to our clinic with exposed methylmethacrylate and two different draining fistulous tracts (Figure 5a). The patient’s medical history was remarkable for a left upper extremity amputation at the age of 26 during World War II. He was otherwise healthy. Preoperatively, it was decided that to preserve upper extremity function the patient would undergo an ALT flap of the previous STSG site. Devitalized temporoparietal bone and previous methylmethacrylate cranioplasty was resected and titanium prosthetic material was used for cranioplasty (Figure 5b). An 8 × 20 cm adipocutaneous ALT flap was used for reconstruction with microsurgical anastomosis performed to the left superficial temporal vessels. Upon 3-month follow-up the patient demonstrated a viable free flap (Figure 5c), ambulation without any reported disturbances, and diminished sensation along the lateral femoral cutaneous nerve.

Case 3

A 78-year-old healthy female patient presented with infiltrating basal cell carcinoma of the right temporoparietal scalp involving the superior periorbital soft tissue (Figure 6). The patient underwent a 10 × 7 cm en bloc resection, including temporal muscle and extradural frontotemporal craniectomy with titanium mesh cranioplasty via an orbitozygomatic approach (Figure 7). A portion of orbital bone was resected requiring titanium implant orbital roof reconstruction. A 10 × 7 cm free ulnar forearm flap, harvested from the patient’s nondominant upper extremity, was used for soft tissue coverage. The donor site was covered with a FTSG from the left groin to the left forearm. The microvascular end-toend anastomosis was from the ulnar vessels to the right superficial temporal vessels.
Postoperatively, mild facial nerve weakness, and postoperative lagophthalmos were noted in the right eye. Upon 5-month follow-up, lid closure and blink improved. At 12-month follow-up, the free flap was viable with moderate thinning. No donor-site morbidity was observed. Upon 28month follow-up, extensive thinning and atrophy of the flap was noted (Figure 8).

Discussion

Reconstructive surgery in the elderly requires a tailored and individualized approach. Derks et al. report no differences in the aged versus young population when assessing quality of life outcomes [29]. Soft tissue reconstruction in traumatic lower extremities shows that ambulation rates were favorable in the elderly population as well [32]. Wester et al. had been able to demonstrate free tissue transfer to the mandible, tongue, and maxilla is safe in patients older than 90 years [33]. Furthermore, multiple microsurgical studies, including scalp, hand, lower extremity, and breast reconstruction found no correlation between chronological age and complications [34,35]. ASA score, an indicator of medical comorbidities, was a predictor of minor and major complications. Specific to scalp reconstruction, selection of the type of repair depends on multiple factors, including cardiovascular risk assessment, ASA score, comorbidities, mental and social health, physical activity, as well as life expectancy.
The advantages of free tissue transfer far exceed skin grafting and local flaps in complex wounds. Consideration of a patient’s functional status and potential for donor site morbidity should be a priority in flap selection. Preserving ambulation, activities of daily living, and social independence is essential in elderly patients. Dhiwakar et al. were able to show lower rates of donor site morbidity than in younger patients [10]. Carey et al. elegantly demonstrated a tailored method of treating an elderly patient by achieving free tissue transfer using only regional and local anesthesia [11]. However, avoiding general anesthesia is seldom necessary. Chronological age alone should not deter the reconstructive surgeon from operating on complex defects. We report different, but tailored, approaches to our patients yielding mixed outcomes but ultimately successful coverage.
As reflected in our series, there are many options for flap choice in repairing the scalp. First described in 1972, McLean and Buncke were able to employ omentum to repair a scalp defect [36]. Since then many different scalp reconstruction methods have been described, including the: vertical trapezius myocutaneous flap [37], deep temporal flap [38], bipedicled frontooccipital flap [39], rectus abdominis flap [40], groin flap [41], radial forearm flap [38,42,43,44,45], serratus flap [1,40,46], parascapular flap [40,47], latissimus dorsi flap [30,46,48,49], and ALT flap [15,18,25,50,51,52,53]. The use of tissue expanders can help in the recruitment of tissue for calvarial coverage, but may not be suitable in certain conditions. Such conditions include a compromised or infected wound bed, wounds with osteoradionecrosis, or in patients with multiple, recurring invasive malignancies [54,55]. Acellular dermal matrix has successfully been used to achieve soft tissue coverage but has significant limitations. The shortcomings involve requiring a relatively cleaner microenvironment and demands the periosteum be preserved [56,57]. Despite shorter operative times, the use of acellular dermal matrix still requires a two-staged procedure. This facilitates a more oncologically sound resection as positive margins can be addressed in the latter procedure. However, the major drawback is subjecting patients to general anesthesia twice.
The ALT flap, latissimus dorsi, and the thoracodorsal perforator flap have emerged as frequent and reliable microsurgical flaps utilized in the repair of the complex scalp defect. Advantages of the ALT flap are its size and bulk, its long vascular pedicle, large caliber vessels, ease of contouring, ability to provide vascularized fascia for duraplasty, and its ability to be successfully dissected without changing intraoperative patient positioning. This facilitates performing a single staged surgery with a two-team reconstructive approach (donor harvesting team and recipient dissection team) [7,17,18,27,50]. The donor site usually requires skin grafting, but Mureau et al. reported increased rates of primary closure in the elderly with defects up to 8 cm in width [58]. Primary closure of the donor site was feasible in 62.5% of our patients. This is likely due to laxity of skin due to the loss of subcutaneous fat and changes in architecture of the collagen and elastin network with time [59]. This likely explains why the ulnar flap may be suboptimal for long-term selection, as depicted in case 3 (Table 1) as soft tissue thickness and adiposity is sparse and predisposed to breakdown. The thoracodorsal perforator artery flap advantages lie in its long pedicle, homogeneous flap thinness, its muscle preserving properties, minimal donor morbidity, and a relatively large stock of soft tissue [19,31,60,61]. We advocate for muscle-sparing adipocutaneous free tissue transfer to prevent longterm atrophy as seen in case 7 with the muscle-only latissimus dorsi (Figure 9, Figure 10 and Figure 11). Nevertheless, historically multiple studies support the latissimus dorsi myocutaneous flap or muscle only with STSG as the workhorse for reconstruction [8,16,30,46,48,62].
Scalp reconstructive algorithms have been reported, but are not uniformly accepted by reconstructive surgeons [38,40,62,63]. Borah et al. describe their most reliable and frequently used flap to be the rectus abdominis flap, followed by the latissimus dorsi [40]. Potparic et al. use an algorithm with the latissimus dorsi flap as the first option, followed by the rectus abdominis flap, and lastly a radial forearm flap. [38] Van Driel et al. advocate for the latissimus dorsi as the initial flap of choice with the ALT flap as a close second. [62] However, the majority of multiple large case series supports the use of the ALT flap as the initial flap selection in repairing complex scalp defects [18,24,25,50,54,64,65]. To date, no randomized clinical trials support the use of one flap versus another in repairing scalp defects.
In case 1, the patient’s active lifestyle prompted us to spare his lower extremities as a donor site. Without impairing his activities of daily living or ability to play tennis we used a thoracodorsal artery perforator flap. Sparing the latissimus dorsi muscle allowed for preservation of upper extremity function, which was paramount to his quality of life. Case 2 exemplified the importance of preventing the potential for devastating donor site morbidity. With one upper extremity, we avoided operating on the patient’s torso and operated on a previous surgical site to avoid creating another wound. Case 7 (Table 1) demonstrates the many approaches to the complex scalp wound and impending complications. Complete coverage of the titanium prosthetic cranioplasty material and calvarium was achieved, but the drawbacks of using a muscleonly flap were exemplified in the rapidly progressing flap atrophy. The denervated myocutaneous flap, although robust and bulky falls short as a long-term solution (Figure 11). Employing adipocutaneous flaps may provide longevity in treatment. However, case 3 demonstrates the drawbacks of using an ulnar adipocutaneous flap as the patient developed overwhelming atrophy upon 28-month follow-up. This was likely due to inadequate tissue adiposity and bulk. Case 5 (Table 1), however, shows that excessive bulk may require liposuction for better cosmesis and contour (Figure 12). Preserving a bulky ALT was found to have excellent long-term results despite the patient undergoing another procedure. Consequently, ulnar flaps and muscle-only flaps have been largely abandoned in scalp reconstruction at our institution.
At presentation 62.5% of our elderly patients presented with a nonhealing wound, which stresses the need for intervention in this cohort. Our series demonstrates a mean of 1.25 operative procedures per patient. Despite concerns for patients undergoing multiple surgeries, the patient with the most comorbidities was eventually able to tolerate an abdominal aortic aneurysm (AAA) repair in the interim.
Recommendations and algorithms have been developed based on multiple small series, making them susceptible to operator bias. In our series, 25% of the patients developed a short term flap complication, 75% of the patients developed minor complications, and mortality was 0%. Our approach to each patient was not based on an algorithm, since available data will likely support any of the aforementioned flaps. We acknowledge that there are advantages and disadvantages to each approach, as well as complexity in operating on elderly patients. We advocate operating on older patients and tailor flap selection to individual patient needs. Our series supports the treatment of complex scalp defects in the elderly boasting 100% soft tissue coverage.

Conclusion

The use of free tissue transfer in complex and large scalp and calvarial defects should be considered the standard of care in the elderly population. Chronological age does not increase mortality or catastrophic flap complications. However, morbidity is increased in the elderly and revisionary surgery is likely. Septua-, octo-, and nonagenarians require an individualized approach for free tissue scalp reconstruction to minimize donor-site morbidity and effectively achieve soft tissue coverage.

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Figure 1. Illustration of a typical scalp defect. Defects will often involve more volume than what initially appears at the surface of the skin, which may manifest as a draining sinus or raised fluctuant focal area. The dense connective tissue and poor compliance of the layers of the scalp can mask the true volume of compromised tissue. Wide excision can leave critical defects of the dura, cranial bone, soft tissue, and skin, which requires coverage. Coverage can be achieved with prosthetic cranioplasty material followed with free tissue transfer.
Figure 1. Illustration of a typical scalp defect. Defects will often involve more volume than what initially appears at the surface of the skin, which may manifest as a draining sinus or raised fluctuant focal area. The dense connective tissue and poor compliance of the layers of the scalp can mask the true volume of compromised tissue. Wide excision can leave critical defects of the dura, cranial bone, soft tissue, and skin, which requires coverage. Coverage can be achieved with prosthetic cranioplasty material followed with free tissue transfer.
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Figure 2. (a) Preoperative image of scalp wound with healthy skin edges marked. (b) Excision and debridement of soft tissue and calvarium with exposed dura. (c) Titanium cranioplasty fixation.
Figure 2. (a) Preoperative image of scalp wound with healthy skin edges marked. (b) Excision and debridement of soft tissue and calvarium with exposed dura. (c) Titanium cranioplasty fixation.
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Figure 3. Muscle-sparing thoracodorsal perforator adipocutaneous flap.
Figure 3. Muscle-sparing thoracodorsal perforator adipocutaneous flap.
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Figure 4. Images of repaired defect with minor contour irregularity at 12-month follow-up.
Figure 4. Images of repaired defect with minor contour irregularity at 12-month follow-up.
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Figure 5. Profile view of preoperative, intraoperative, and postoperative images of case 2. (a) Preoperative image of fistulous tracts and nonhealing wounds. (b) Titanium mesh inset with a larger soft tissue defect. (c) Three months following an ALT perforator free flap. ALT, anterolateral thigh. (Permission obtained from the publisher.).
Figure 5. Profile view of preoperative, intraoperative, and postoperative images of case 2. (a) Preoperative image of fistulous tracts and nonhealing wounds. (b) Titanium mesh inset with a larger soft tissue defect. (c) Three months following an ALT perforator free flap. ALT, anterolateral thigh. (Permission obtained from the publisher.).
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Figure 6. Infiltrating basal cell carcinoma affecting the frontal and periorbital region.
Figure 6. Infiltrating basal cell carcinoma affecting the frontal and periorbital region.
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Figure 7. (a) Extent of resection involving the roof of the orbit. (b) Cranioplasty with titanium mesh prior an ulnar adipocutaneous flap.
Figure 7. (a) Extent of resection involving the roof of the orbit. (b) Cranioplasty with titanium mesh prior an ulnar adipocutaneous flap.
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Figure 8. (a) Three-month postoperative result with good orbital contour; (b) 12-month postoperative result with minimal atrophy; (c) 28-month follow-up showing excessive atrophy with visible contours of mesh.
Figure 8. (a) Three-month postoperative result with good orbital contour; (b) 12-month postoperative result with minimal atrophy; (c) 28-month follow-up showing excessive atrophy with visible contours of mesh.
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Figure 9. Preoperative frontal, oblique, and profile images depicting the extent of the patient’s prior ALT flap and nonhealing wound. ALT, anterolateral thigh.
Figure 9. Preoperative frontal, oblique, and profile images depicting the extent of the patient’s prior ALT flap and nonhealing wound. ALT, anterolateral thigh.
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Figure 10. (a) Extensive debridement of soft tissue and methylmethacrylate mesh ultimately exposing dura. (b) Titanium mesh cranioplasty. (c) Inset of free latissimus dorsi muscle flap.
Figure 10. (a) Extensive debridement of soft tissue and methylmethacrylate mesh ultimately exposing dura. (b) Titanium mesh cranioplasty. (c) Inset of free latissimus dorsi muscle flap.
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Figure 11. (a) Three months following latissimus dorsi muscle and STSG. (b) Ensuing atrophy of the flap over the next month. STSG, split-thickness skin graft.
Figure 11. (a) Three months following latissimus dorsi muscle and STSG. (b) Ensuing atrophy of the flap over the next month. STSG, split-thickness skin graft.
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Figure 12. (a) Preoperative infected STSG and local tissue rearrangement. (b) Intraoperative extent of resection and titanium mesh cranioplasty. (c) The 10-month postoperative result following an ALT flap (with hair displaced and combed over). STSG, split-thickness skin graft.
Figure 12. (a) Preoperative infected STSG and local tissue rearrangement. (b) Intraoperative extent of resection and titanium mesh cranioplasty. (c) The 10-month postoperative result following an ALT flap (with hair displaced and combed over). STSG, split-thickness skin graft.
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Table 1. Results and reconstructive details.
Table 1. Results and reconstructive details.
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Table 2. Follow-up times, complications, and revisions.
Table 2. Follow-up times, complications, and revisions.
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MDPI and ACS Style

Sosin, M.; Chaudhry, A.; Cruz, C.D.L.; Bojovic, B.; Manson, P.N.; Rodriguez, E.D. Lessons Learned in Scalp Reconstruction and Tailoring Free Tissue Transfer in the Elderly: A Case Series and Literature Review. Craniomaxillofac. Trauma Reconstr. 2015, 8, 179-189. https://doi.org/10.1055/s-0034-1393725

AMA Style

Sosin M, Chaudhry A, Cruz CDL, Bojovic B, Manson PN, Rodriguez ED. Lessons Learned in Scalp Reconstruction and Tailoring Free Tissue Transfer in the Elderly: A Case Series and Literature Review. Craniomaxillofacial Trauma & Reconstruction. 2015; 8(3):179-189. https://doi.org/10.1055/s-0034-1393725

Chicago/Turabian Style

Sosin, Michael, Arif Chaudhry, Carla De La Cruz, Branko Bojovic, Paul N. Manson, and Eduardo D. Rodriguez. 2015. "Lessons Learned in Scalp Reconstruction and Tailoring Free Tissue Transfer in the Elderly: A Case Series and Literature Review" Craniomaxillofacial Trauma & Reconstruction 8, no. 3: 179-189. https://doi.org/10.1055/s-0034-1393725

APA Style

Sosin, M., Chaudhry, A., Cruz, C. D. L., Bojovic, B., Manson, P. N., & Rodriguez, E. D. (2015). Lessons Learned in Scalp Reconstruction and Tailoring Free Tissue Transfer in the Elderly: A Case Series and Literature Review. Craniomaxillofacial Trauma & Reconstruction, 8(3), 179-189. https://doi.org/10.1055/s-0034-1393725

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