Plastic surgery restores form and function through reconstructive procedures, cosmetic enhancements, and body contouring.
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The surgery begins with the patient under anesthesia. The head is positioned on a specialized headrest (often a “horseshoe” or gel ring) to allow access to the entire scalp while protecting the face and eyes. The hair is secured with sterile gel or rubber bands to keep it out of the wound.
The scalp is prepped with a sterile solution. If a skin graft or free flap is planned, the donor site (thigh, back) is also prepped. Draping is extensive to create a large sterile field, allowing the surgeon to move tissue freely without contamination.
The first surgical step is removing the pathology. For trauma, this means debridement—removing all dead, contaminated, or crushed tissue until healthy, bleeding edges are reached. Cancer involves excising the tumor with the pre-planned safety margins.
Intra-operative pathology (frozen sections) is often used. The excised tissue is sent to the lab immediately for margin evaluation. The reconstruction does not begin until the pathologist confirms that all cancer is gone. This ensures that cancer is not buried under a complex flap.
To gain tissue laxity, the surgeon undermines the scalp, separating the galea from the periosteum. This allows the scalp to slide. If more length is needed, “galeal scoring” is performed.
The surgeon makes multiple parallel cuts on the underside of the galea (the tight fibrous layer) without cutting the blood vessels in the subcutaneous fat. This releases scalp rigidity, allowing it to stretch significantly (“accordion effect”) to cover the defect without tension.
Based on the defect size, a local flap is designed. Standard designs include the Rotation Flap (curved arc), Transposition Flap (rectangular tongue), or the “Pinwheel” Flap (multiple rotating flaps). The flap is lifted, ensuring the identified artery is included in its base.
The flap is rotated into the defect. The geometry distributes the tension over a large area rather than focusing it on the wound edge. Standing cones of excess skin (“dog ears”) are trimmed or corrected to ensure a flat contour.
If the defect cannot be closed with flaps, a skin graft is harvested. A dermatome (electric shaver) takes a thin sheet of skin from the thigh. The pericranium (membrane over the bone) must be intact to support the graft.
The graft is meshed (small slits cut into it) or applied as a sheet. It is secured with staples or sutures. A bolster dressing or Wound VAC is placed over it to press it firmly against the bed, preventing fluid from lifting it off.
If the periosteum is missing and bare bone is exposed, a skin graft will not survive. The surgeon must modify the bone to allow healing. The outer table of the skull is burrowed down or drilled with small holes (“trephination”).
This exposes the bleeding diploic space (marrow) of the skull. Over a few weeks, granulation tissue forms in these holes, creating a vascular bed that can eventually support a skin graft. Alternatively, a vascularized muscle flap is brought in to cover the bone immediately.
For massive defects, a free flap is performed. The latissimus dorsi muscle or anterolateral thigh flap is harvested. The surgeon uses a microscope to suture the flap’s artery and vein to the superficial temporal or facial vessels on the head.
This is the most complex reconstructive tier. It requires precise vessel anastomosis using sutures thinner than a hair. Once blood flow is established, the flap turns pink. The donor muscle is then covered with a skin graft. This provides a thick, healthy cushion over the brain.
If tissue expansion is chosen, this surgery involves placing the device. Incisions are made remote from the defect. A pocket is created under the galea. The uninflated silicone expander is inserted.
The injection port is placed under the skin in an accessible spot. The wound is closed meticulously to prevent the device from extruding. No expansion is done immediately; the wound is allowed to heal for 2-3 weeks before inflation begins.
Scalp wounds are closed in layers. The galea is sutured with high-strength, absorbable sutures to maintain tension. The skin is closed with staples or non-absorbable sutures. Staples are commonly used on the scalp as they are gentle on hair follicles and quick to place.
Suction drains are almost always placed under large flaps. The scalp can bleed significantly post-op, and a hematoma (blood collection) can kill a flap by putting pressure on the vessels. Drains remove this fluid and suck the flap down onto the skull.
A distinct “head wrap” or turban-style dressing is applied. It provides gentle, even compression to minimize swelling and support the flaps. It must be tight enough to prevent bleeding but not so tight as to compromise blood flow to the flap edges.
The ears are carefully padded to prevent pressure necrosis. For free flaps, a “window” is left in the dressing so nurses can check the flap’s color and temperature without removing the bandages.
Patients are monitored in the recovery room. Head elevation (30-45 degrees) is mandatory to reduce venous congestion and swelling. Blood pressure is strictly controlled; too high causes bleeding, too low causes flap ischemia.
For free-flap patients, monitoring is intensive (in an ICU setting). Hourly checks of the flap using Doppler or clinical exam are performed for the first 24-48 hours. Any sign of vascular compromise necessitates an immediate return to the operating room.
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Scalp surgery is surprisingly well-tolerated. The scalp has many nerves, but once the initial healing begins, the pain is usually described as a tight headache rather than sharp pain. Tylenol and mild narcotics are usually sufficient after the first few days.
Those are surgical drains. They remove blood and fluid that collects under the skin. They are temporary and are typically removed within 2 to 5 days as drainage decreases. They prevent fluid pockets that could hurt the healing.
You must sleep with your head elevated on 2 or 3 pillows, or in a recliner, for the first 1-2 weeks. This uses gravity to drain swelling away from your face and head. Do not sleep on the side of the surgery to avoid pressure on the wound.
Typically, you can let water run gently over the incisions after 48 hours, but you cannot scrub or use shampoo vigorously. If you have a skin graft, you must keep it dry for about a week. Your surgeon will give you specific instructions for the timeline.
Gravity causes the scalp swelling to travel downward. It is very common to get black eyes or swollen cheeks 2-3 days after scalp surgery, even if the surgery was on the top of your head. This is normal and will resolve in a week.
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