Menu		Inservice Exam - 2005 Tissue Expansion A 65-year-old woman who has undergone multiple resections for recurrent lentigo maligna melanoma with repeated central advancements of the remaining scalp via skin grafting over the past 10 years has frequent irritation of the skin at the grafting sites (shown above). No evidence of further disease has been noted over the past four years. Which of the following is the most appropriate management at this time? (A) Full-thickness skin grafting (B) Micrograft hair transplantation (C) Rerotational flap advancement (D) Staged excision and primary closure (E) Tissue expansion The correct response is Option E. Because of continued skin breakdown in this area of postsurgical alopecia, tissue expansion followed by adjacent tissue transfer is the most appropriate surgical procedure at this time. This patient has had multiple excisions with repeated advancement followed by skin grafting. The remaining native vessels should be sufficient to supply the expanded scalp skin. Tissue expansion and coverage are usually tolerated well by patients of this age. Hair transplantation is unlikely to be successful in this patient because of extensive scars in the area. Staged excision of the prior skin grafts and primary closure will not improve this patient’s alopecia and are unlikely to relieve the skin irritation caused by the thinned skin over the calvaria. Because advancement has already been done, little additional advancement can be achieved without back-grafting exposed areas. Full-thickness grafts will not allow sufficient hair growth or replacement. References: 1. Argenta LC, Marks MW, Pasyk DA. Advances in tissue expansion. Clin Plast Surg. 1985;12:159. 2. Oishi SN, Luce EA. The difficult scalp and skull wound. Clin Plast Surg. 1995;22:51-59.
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