Plastic surgery restores form and function through reconstructive procedures, cosmetic enhancements, and body contouring.
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The scalp reconstruction consultation is a rigorous diagnostic session. It begins with a detailed history of the defect: is it from a recent trauma, a growing tumor, or a chronic wound? The surgeon reviews pathology reports from any cancer resections to determine tumor type and clearance margins.
The physical examination focuses on the defect itself and the surrounding scalp. The surgeon assesses the quality of the remaining tissue—is it healthy, scarred, or irradiated? This assessment determines whether local tissue can be used or if distant tissue must be recruited.
Standard X-rays are rarely sufficient. Computed Tomography (CT) scans with 3D reconstruction are often ordered to assess the underlying bone. The surgeon needs to know if the outer table of the skull is intact or if the defect extends through the bone to the dura.
Magnetic Resonance Imaging (MRI) may be used to evaluate soft-tissue extent, particularly for tumors such as sarcomas that can spread along nerve sheaths or fascial planes. This imaging allows for precise pre-operative mapping of the resection and reconstruction limits.
A critical component of the exam is assessing scalp laxity. The surgeon manually palpates and moves the scalp to determine the available “give.” The scalp is naturally tighter in the vertex (crown) and looser in the temporal and parietal (side) regions.
The “pinch test” helps determine if primary closure or local flaps are feasible. If the scalp is immobile, mechanical techniques such as galeal scoring (cutting the fibrous layer) will be planned, or alternative coverage options, such as grafts, will be discussed.
Since scalp flaps rely on specific arteries, the surgeon must verify that these arteries are patent (open) and in the correct location. A handheld Doppler ultrasound device is used to trace the path of the superficial temporal, occipital, and supratrochlear arteries.
This mapping is marked on the patient’s skin. It ensures that when a flap is designed, the surgeon knows exactly where the blood supply enters the tissue. This prevents the catastrophic error of cutting the artery that keeps the flap alive.
Nicotine is a potent vasoconstrictor that creates a “chemical tourniquet,” reducing blood flow to the skin by up to 40%. In scalp surgery, where flaps are rotated and stretched, compromised blood flow leads to necrosis (tissue death) of the flap edges or the entire reconstruction.
A strict zero-tolerance policy is enforced. Patients are required to stop all nicotine products—vapes, patches, gum, and smoke—for at least 4 weeks before and after surgery. This ensures the microcirculation is robust enough to support flap healing.
Wound healing places a significant metabolic demand on the body, especially when large open areas or skin grafts are present. Protein is the building block of repair. The surgeon evaluates nutritional markers, such as albumin and Prealbumin, to screen for malnutrition.
Patients are often placed on a high-protein diet and given supplements (like Arginine, Zinc, and Vitamin C) in the weeks leading up to surgery. Optimizing glucose control in diabetic patients is also critical to prevent infection and wound breakdown.
If tissue expansion is chosen, the planning involves determining the number, size, and shape of the expanders. The surgeon marks the proposed placement sites on the healthy scalp. The goal is to place the expander where it will grow the most useful hair-bearing skin.
Logistics are discussed in detail. The patient must commit to weekly office visits for injections over 2 to 4 months. They must also be prepared for the temporary cosmetic deformity of the expanding “bumps” on their head during the process.
The surgeon and patient discuss the aesthetic goals regarding the hairline. If the reconstruction will alter the hairline position, this is demonstrated in the mirror. For men with male pattern baldness, the planning may differ from that of those with a full head of hair.
In some cases, the reconstruction may intentionally recruit non-hair-bearing skin (like from the forehead) to close a defect, with a plan for future hair transplantation. Managing expectations about temporary or permanent alopecia is a key part of the consent process.
Scalp reconstruction can be a lengthy procedure. A complete medical clearance is required to ensure the patient can tolerate general anesthesia. This includes cardiac evaluation (EKG), lung function tests, and blood work to check for anemia or clotting disorders.
The anesthesia team reviews the airway, as head and neck positioning is critical during surgery. For free flap cases that may last 6-10 hours, the patient’s physiological reserves are carefully scrutinized.
If the surgery is for a tumor, the previous biopsy results are reviewed. The surgeon must know the aggressive nature of the cancer to plan the “margins”—how much extra healthy tissue must be removed around the tumor.
Sometimes, a “mapping biopsy” is performed around the visible tumor to check for sub-clinical spread. This helps prevent the scenario where the surgeon removes the cancer but finds positive margins on the final pathology report.
Recovery from scalp surgery varies. Simple closures may require only a day off, while free flaps require a week in the hospital. Patients are advised to arrange for assistance with hair washing and wound care, as raising the arms or bending over may be restricted.
Post-operative supplies—antibiotic ointment, non-stick dressings, loose-fitting hats or scarves—are discussed so the patient can prepare their home (“nesting”) before the surgery date.
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No, modern techniques rarely require shaving the entire head. We typically only shave a small strip along the incision lines or the immediate area surrounding the defect. We try to preserve as much hair as possible to help hide the incisions afterwards.
We use a Doppler ultrasound device during the consultation. It allows us to hear the pulse in your scalp arteries. We mark these arteries on your skin to ensure our surgical plan includes a strong blood supply for the reconstructed tissue.
You will likely need to stop blood thinners (like aspirin, Plavix, or Coumadin) for a specific period before surgery to prevent excessive bleeding and hematomas. We will coordinate this with your prescribing cardiologist or primary care doctor to ensure it is done safely.
Scalp surgery can be bloody due to its rich vascularity. For routine procedures, transfusions are rare. For complex, extensive resections or free flaps, the risk is higher. We will check your blood counts beforehand and prepare accordingly.
You cannot wear a wig immediately after surgery because it can rub against the fresh incisions and trap bacteria. Once the wounds are fully healed (usually 4-6 weeks), you can typically resume wearing a wig or hairpiece.
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