Peculiarities of surgical treatment of scalp soft tissue defects in combat trauma

Objective. To improve the results of surgical treatment of soft tissue defects of the scalp in combat trauma. Materials and methods. The study included 9 patients with medium–sized soft tissue defects of the scalp who were treated at the Department of Plastic, Reconstructive and Restorative Surgery

Scalp reconstruction has been known since the time of Ancient Egypt (3000 BC), and its development was driven by the need to treat scalp wounds sustained by soldiers during battles and high-velocity injuries.The wounded often died due to bleeding, chronic infections and intracranial complications.
Injuries to the scalp were also quite common in America, due to the indigenous traditions of removing the scalps of enemies.Mentions of scalp reconstruction date back to the early 1900s, and scalp replantation as a full-layer skin graft without restoring blood supply is described.Such grafts were always mummified [1].
Modern scalp reconstructive surgery emerged from the experience of the First and Second World Wars, when saving lives was the primary concern, and cosmetic subtleties and preservation of sensitivity were secondary or even unimportant.Progress has been made in the use of various scalp flaps that have been proposed to solve specific reconstruction problems.Thus, V. H. Kazanjian (1953) demonstrated the advantages of notching the tendon helmet for better displacement of local flaps, and M. Orticochea published the 4-flap technique for closing large defects in 1967, which he improved in 1971 [2].E. K.  in 1984 reported the reconstruction of a defect that occupied half the scalp area with scalp tissue using the extension technique.
Thus, according to many authors, if it is impossible to close the defect with primary tension, the next best technique from an aesthetic point of view is the use of local flaps [4][5][6].In addition, from a technical point of view, this technique is one of the simplest, so it can be used without specific knowledge and skills.These characteristics can satisfy the require-ments for the reconstruction of combat injuries, since, given the effectiveness of the surgical intervention, its simplicity and speed, it is possible at the evacuation stage.However, the number of patients hospitalised due to unsatisfactory treatment results refutes this statement, and the incidence of complications is higher than the corresponding figures in the literature -from 6 to 25% [7][8][9][10].
The aim of the study is to improve the results of surgical treatment of scalp soft tissue defects in combat trauma.

Materials and methods
The study is based on the results of treatment of 9 patients with scalp soft tissue defects sustained during hostilities at the National Research Centre of Surgery and Transplantation named after A.A. Shalimov in 2022-2024.4 out of 9 patients had complications after treatment of these defects in other medical institutions.All patients are men.
Anthropometric, laboratory and instrumental methods, including colour duplex mapping and computed tomographic (CT) angiography, were used, as well as research methods and photo documentation.
In all patients, the examination revealed numerous scars of adjacent areas as a result of trauma or surgical interventions.In patients with complications, complete or partial necrosis of the displaced flaps was noted.
Upon admission, in addition to general clinical examinations, patients underwent CT angiography to determine the condition of the skull vault bones and individual architectonics, as well as colour duplex mapping of the main vascular bundles to plan the flap template.
The classification of H. U. Jang and Y. W. Choi [11], according to which they were divided by location: frontopari- The Ukrainian Journal of Clinical Surgery etal/temporal, temporal/temporoparietal, occipital; by size: small ( 10 cm 2 ), medium (10-50 cm 2 ), large (>50 cm 2 ) and depth: without bone exposure, with bone or dura exposure.All patients had medium-sized frontoparietal and temporoparietal defects with exposure of the bones of the skull vault.
In all patients, randomised rotational flaps of local tissues were used to close scalp soft tissue defects, which were formed not in an arbitrary form, but taking into account the direction and location of scars, individual angioarchitecture and in compliance with generally accepted optimal ratios of flap parameters.We used 1, 2, 3 flaps depending on the individual characteristics of the adjacent areas.
The results of treatment were evaluated by the presence/ absence of complications, which were divided into minor (slow healing, infection, failure of the wound edges with exposure of bone or titanium plate, seroma of the donor site) or major (flap necrosis, haematoma requiring revision surgery, drying of the bones of the skull vault, sequestration with sepsis), as well as aesthetically -hair restoration.

Results
Only 1 patient had a minor complication -slower healing and partial failure of the sutures healed by secondary tension.
All patients had good aesthetic and functional results with a short rehabilitation period.Here is a clinical observation.Patient V., 25 years old, came to the clinic with complaints of a full-layer soft tissue defect of the left frontoparietal region.Anamnesis: tangential penetrating wound in the left frontal region with an impression fracture of the frontal bone, extension of the linear fracture to the frontal bone and the base of the anterior cranial fossa on the left.During the evacuation stages, several repeated surgical treatments of the wounds of the frontoparietal area, osteonectomy and plastic surgery of the left frontal defect using a nuchal flap in the form of fragile postoperative scars of the left frontoparietal-temporal region were performed, and the bone defect of the frontal bone was replaced with autobone with an area of 33.3 cm 2 .
The examination revealed a full-layer soft tissue defect with an area of 16.5 cm 2 and scars in the adjacent areas.The bottom of the defect is bone with trephination holes, partially covered with granulation tissue (Fig. 1).
A computed tomography (CT) scan revealed a 46 28 mm thinning of the frontal bone in the projection of the soft tissue defect (Fig. 2).There were also 4 trephination holes.

The Ukrainian Journal of Clinical Surgery
Contrast injection and examination of the main vessels of the external carotid artery basin revealed that their lumen was uniform, without filling defects (Fig. 3).
Since the direction of the scars in the temporal region prevented the formation of a flap with adequate haemodynamics, it was decided to close the defect with a rotational flap from the occipito-parietal region (Fig. 4).
During the surgical intervention at the stages of mobilisation (Fig. 5, a) and transposition (Fig. 5, b), the formed rotational occipito-parietal flap was hemodynamically compensated.
The defect of the donor site was initially closed with a rotational temporal zone flap, as the direction of scarring in this area allowed the formation of a hemodynamically compensated flap of the required size (Fig. 6).
A good aesthetic and functional result was obtained (Fig. 7).
The overwhelming majority of the literature notes the advantages of local flaps, as this method moves tissues with hair, and the incisions required for flap harvesting can often be hidden by thick hair [9,10].We used exclusively rotational flaps, which is in line with the statement of M. Sokoya and colleagues [9], who assumed that isolated advanced flaps were ineffective due to the thick and inelastic scalp skin and used a combination of advanced and rotational flaps [9].

The Ukrainian Journal of Clinical Surgery
To date, most authors also use one or more rotational yinyang flaps [1,4,5].However, all authors agree that the amount of scalp soft tissue available for reconstruction is limited in many patients due to a deficit in its elasticity, which limits the capabilities of this technique, and there is a need to form flaps much larger in area than those used for face and neck defects [10,12].Therefore, the authors noted the best results in patients with medium-sized defects [10].However, this technique, according to some authors, is a choice only for two specific groups of patients: severely debilitated patients at risk, in whom only local anaesthesia is possible, and patients who need immediate closure of the defect with hairline tissue [10].We studied the results of treatment of patients belonging to the 2nd group.

Conclusions
Thus, the use of local flaps meets the requirement of "like for like".The method is simple and quick to perform, and the aesthetic result is superior to other methods.Local flaps can cover defects of any depth, including avascular structures and bare bone.The use of local flaps is the "gold standard" for the reconstruction of small and medium-sized soft tissue defects of the scalp.

Fig. 3 .
Fig. 3. CT angiography: Vessels of the head and neck without filling defects.