1. JAMA Facial Plastic Surgery Journal Club Slides: Dermal Regeneration Template for Full-Thickness Scalp Defects
Richardson MA, Lange JP, Jordan JR. Reconstruction of full-thickness scalp defects using a dermal regeneration template. JAMA Facial Plast Surg. Published online November 25, doi: /jamafacial

2. Introduction
Large full-thickness scalp defects pose a reconstructive problem and commonly require microvascular free flap reconstruction.
Herein, a novel alternative reconstructive technique using the application of Integra bilayer wound matrix followed by delayed split-thickness skin grafting is presented.
This is a retrospective review (January 1, 2008, to December 31, 2014) of 10 patients who underwent reconstruction of large scalp defects using the application of Integra bilayer wound matrix followed by delayed split-thickness skin grafting.
The patients in this study had excellent skin graft and wound closure outcomes. Of the 10 patients, 9 showed a 100% initial take of the skin graft to the defect site. Only 1 patient showed a 95% to 100% initial take. Adequate coverage of the wound bed was achieved with acceptable cosmetic results. One patient experienced radiotherapy-induced wound breakdown 3.5 months after completion of intensity-modulated radiotherapy.

3. Purpose
The purpose of this study is to describe a novel and effective reconstructive technique for full-thickness scalp defects that can be performed quickly without general anesthesia or free flap reconstruction.

4. Relevance to Clinical Practice
Historically, the reconstruction of large full-thickness scalp defects has been a challenge to surgeons owing to scalp anatomy, limited mobility of the scalp, and poor vascularity of the calvarium. Techniques for repair have included primary closure, tissue expansion, skin grafting, local flaps, and microvascular free tissue transfer. Each of these reconstructive options has different limitations and complications.
More recently, free tissue transfer with microvascular anastomosis has been favored for larger defects. This method involves significant risk, hospitalization, and likely increased financial cost.
The described method of Integra bilayer wound matrix followed by delayed split-thickness skin grafting is a highly successful and cosmetically pleasing outpatient alternative for reconstruction of these defects.

5. Description of Evidence
Ten patients underwent reconstruction of large scalp defects using the application of Integra bilayer wound matrix followed by delayed split-thickness skin grafting from January 1, 2008, to December 31, 2014.
Technique
Patients underwent full-thickness scalp resection, including removal of the periosteum overlying the outer table of the skull in 6 of 10 patients.
After confirmation of clear margins, Integra was placed into the wound bed with the semipermeable silicon layer on the superficial aspect of the wound. It was then coated in bacitracin ointment and secured with 2 layers of an Allevyn dressing soaked in gentamicin sulfate solution (160 mg per 200 mL of normal saline solution).
Patients were taken to the operating room approximately 21 days later and the Allevyn dressing and semipermeable silicone layer were removed. A 0.04-cm (0.016-inch) skin graft was harvested and meshed at a ratio of 1:1.25 and sutured into place. Bacitracin was applied and a gentamicin-soaked Allevyn dressing was again placed.

6. Description of Evidence
Postoperative care
All patients returned to the clinic 7 to 10 days postoperatively for removal of the Allevyn dressing and assessment of the skin graft.
Patients were instructed to leave the wound uncovered but to apply bacitracin ointment at least twice daily until the wound was completely epithelialized.

7. Description of Evidence
Reconstructive Technique for Full-Thickness Scalp Defects

8. Description of Evidence
Patient Results

9. Controversies and Consensus
Limitations of Technique
This technique is not recommended in cases that require full-thickness calvarial resection that results in dural exposure. In these cases, microvascular free flap reconstruction is usually required.
This technique results in an area of scalp devoid of hair and therefore is less suitable for patients with hair-bearing scalps.
The technique requires 2 surgical procedures and multiple weeks of wound care, which may be a burden socially or financially for some patients.
For some patients, this presents a viable alternative reconstructive option for large scalp defects.

10. Comment Future Implications and Research
We have more recently begun to perform the resection, initial Integra placement, and second-stage split-thickness skin graft reconstruction under intravenous sedation with local anesthetic rather than general endotracheal anesthesia. This potentially results in quicker postoperative recovery from anesthesia and decreased risk of major anesthesia-related complications in these sometimes frail and elderly patients.
Future studies directed at analyzing the cost of this technique compared with other alternative reconstructive options are ongoing.

11. Conclusions
In this series, we present a technique for reconstruction of large full-thickness scalp defects that has low morbidity and can be performed on an outpatient basis with minimal wound care. This technique provides the surgeon with an alternative to other reconstructive options, including microvascular free tissue transfer, for repair of large full-thickness scalp defects with excellent results. The procedure can be performed under sedation and local anesthesia for patients with risk factors for general anesthesia.

12. Conflict of Interest Disclosures
Contact Information
If you have questions, please contact the corresponding author:
Matthew A. Richardson, MD, Department of Otolaryngology and Communicative Sciences, University of Mississippi Medical Center, 2500 N State St, Jackson, MS
Conflict of Interest Disclosures
None reported.