Surgical Treatment of Scalp Soft Tissue Defects

The dissertation is devoted to the surgical treatment of scalp soft tissue defects. The study examines clinical variants of such defects depending on their area and depth of tissue involvement, develops strategies and indications for various surgical treatment methods, and optimizes the technical aspects of expander dermotension application. Special attention is given to the analysis of short-term and long-term results of surgical interventions.

The scientific novelty of the work lies in the systematization of existing methods of surgical treatment of scalp soft tissue defects taking into account topographic-anatomical features, size, and depth of involvement, as well as in the development and implementation of expander dermotension for open defects. The practical significance lies in determining indications for various surgical interventions and improving the method of expander implantation in the hairy part of the scalp.

The research results have been implemented in the surgical practice of departments of plastic and reconstructive microsurgery of the Republican Scientific Center of Cardiovascular and Thoracic Surgery in Dushanbe, departments of neurosurgery of the National Medical Center of the Republic of Tajikistan, and the Republican Commercial Scientific Educational and Production Center of Reconstructive Surgery.

Relevance of the topic. Soft tissue defects of the scalp occur mainly after trauma, burns, and tumor resection. Traditionally, such soft tissue defects are covered by harvesting flaps according to the principles of local plastic operations, and for more extensive defects, by skin grafts. (Grishin I.N., Podgaysky V.N., Serebro V.P., Zalutsky I.V., 1989 [52]; Burlakov A.S., Denisov K.A., 1994 [20]). Experience reveals a number of drawbacks of this technique. Thus, the possibilities of local plastic operations are limited by the size of defects, and therefore these methods do not allow covering extensive defects of the scalp soft tissues. In addition, traditional methods of covering scalp soft tissue defects often only temporarily relieve the patient of wound defects, since secondary complications that frequently arise (necrosis of skin grafts, marginal necrosis of transposed flaps due to excessive tension, contraction of skin grafts, development of trophic ulcers, etc.) negatively affect treatment outcomes, contributing to their recurrence (Buryan F., 1967, [32]). The introduction of microsurgical technologies and tissue expansion through the use of various types of microsurgical flaps with simultaneous revascularization, and the augmentation of healthy skin in close proximity to the defect using tissue expanders, have significantly expanded the possibilities of surgical rehabilitation of patients with extensive scalp soft tissue defects. (Nerobeev A.I., 1985 [87, 88]; Konovalov A.N., 2001 [69]).

Modern methods of balloon dermotension and microsurgical autotransplantation of tissues make it possible to create a natural, full-fledged skin cover (Vaganova N.A., Moroz V.Yu., 2005 [39, 40]; Grigoryeva T.G. et al., 2005 [54, 55]; Kurbanov U.A., 2006 [73]).

Despite the significant achievements of reconstructive and plastic surgery in the treatment of scalp soft tissue defects, many unresolved questions still exist. The problem of eliminating scalp soft tissue defects is considered in the general context of soft tissue defects of the body without regard to local characteristics. The lack of systematization of existing methods for eliminating scalp soft tissue defects often contributes to unsatisfactory outcomes of surgical interventions. To date, there are no clearly developed indications for the use of various types of local plastic operations, microsurgical autotransplantations, and expander dermotension.

The goal of the work is to improve the results of surgical treatment of scalp soft tissue defects. Objectives:

1. To study the clinical variants of scalp soft tissue defects depending on the area and depth of tissue involvement.

2. To improve the strategy and determine indications for the use of various surgical treatment methods depending on the size of scalp soft tissue defects of the hairy part of the head.

3. To optimize the technical aspects of expander dermotension in alopecias and to study its possibilities in the treatment of open scalp soft tissue defects.

4. To study the short-term and long-term results of the use of various surgical treatment methods for scalp soft tissue defects.

Scientific novelty. Having studied the features of scalp soft tissue defects, and taking into account the possibilities of various methods of their elimination depending on their area, three variants of scalp soft tissue defects have been identified — small, medium, and large. Existing methods of surgical treatment of scalp soft tissue defects have been systematized from the standpoint of topographic-anatomical features of the head, size, and depth of soft tissue involvement. A method of expander dermotension for open, relatively fresh, scalp soft tissue defects has been developed and implemented. On the basis of an analysis of the effectiveness of existing operative techniques, indications for the use of various types of operative interventions aimed at eliminating scalp soft tissue defects have been developed.

Practical significance. The determination of indications for various surgical interventions allows their proper application depending on the area of scalp soft tissue defects. The developed method of expander dermotension for large open scalp soft tissue defects makes it possible to simultaneously solve two tasks — to create a full-fledged soft tissue cover and to prevent the development of an area of alopecia. The improvement of the method of expander implantation in the hairy part of the head by creating access away from the defect and performing surgery against the background of infiltration with a vasoconstrictor solution allows a significant reduction of intraoperative blood loss and the risk of complications.

Main findings to be defended:

1. Scalp soft tissue defects have been divided into three clinical variants depending on their area: I — small defects — round-shaped defects and linear alopecias with a width not exceeding 1.5 cm; II — medium defects with an area of 6 to 21 cm; III — large defects with an area exceeding 21 cm.

2. Small scalp soft tissue defects are eliminated by approximating the edges and applying direct sutures, while medium defects require the use of local plastic operations. The most effective method for eliminating large scar defects (alopecia) of the scalp soft tissues is expander dermotension. Large open scalp soft tissue defects can be eliminated in a single stage using transposed and microsurgical flaps, but an area of alopecia inevitably develops in the process.

3. The use of expander dermotension makes it possible to simultaneously solve the problem of an open defect and a large area of alopecia.

4. Among all methods of treating large scalp soft tissue defects, the best functional and aesthetic long-term results are observed after local plastic operations and expander dermotension.

Implementation of research results. The research results have been implemented in the surgical practice of departments of plastic and reconstructive microsurgery of the Republican Scientific Center of Cardiovascular and Thoracic Surgery in Dushanbe, departments of neurosurgery of the National Medical Center of the Republic of Tajikistan, and the Republican Commercial Scientific Educational and Production Center of Reconstructive Surgery.

Presentation of the work. The main findings of the dissertation were presented at: a meeting of the Association of Surgeons of Tajikistan (2004); a Republican Scientific and Practical Conference "Modern Technologies in Medicine" (Tursunzade, 2005); the 54th annual conference of TSMTU with international participation dedicated to the 90th anniversary of Z.P. Khodjaev and Ya.A. Rakhimov (Dushanbe, 2006); a Republican Scientific and Practical Conference with international participation, "The Role of Modern Medical Technology in Improving the Quality of Life of the Patient" (Tursunzade, 2007), at a meeting of the Department of Neurosurgery of TSMTU (2007).

Publications. Based on the materials of the dissertation, 8 scientific works have been published and 1 certificate for an invention has been obtained.

Volume and structure of the work. The dissertation is written in Russian. It consists of an introduction, 4 chapters, a conclusion, findings, practical recommendations, and a list of references. The work is presented on 98 pages of typescript, including 31 figures, 6 tables, 1 diagram, and a list of references consisting of 153 sources.