Bilayer wound matrix-based cutaneous scalp reconstruction: A multidisciplinary case control analysis of factors associated with reconstructive success and failure

Published:April 22, 2021DOI:



      Scalp wounds pose reconstructive challenges due to the lack of skin elasticity, potential for compromised adjacent tissue, and desire for the restoration of esthetic contour. Bilayer Wound Matrix (BWM) has been successfully employed as a treatment modality for complex, full-thickness wounds of the scalp. We aimed to highlight risk factors for BWM success and failure in complex wounds of the scalp.


      A retrospective case-control study was performed from 2012 to 2019 of adult subjects who presented to plastic or dermatological surgery with complex scalp defects with or without exposed calvarium, who underwent staged reconstruction with BWM and split-thickness skin grafting or secondary intention. Success was defined as complete wound re-epithelialization within 90-day follow-up without additional operative procedures for wound coverage. Demographics, comorbidities, treatment history, wound characteristics, and clinical course were analyzed and correlated with reconstructive outcomes.


      In total, 127 subjects were identified for inclusion, with mean age 74.6 ± 12.2 years, defect area 80.2 ± 89.4 cm2, and wound age 10.0 ± 65.4 days. Successful wound reconstruction occurred in 107 (84%) subjects. Postoperative wound infections were an independent predictor of BWM failure at 90 days (Odds Ratio: 6.4, 95% Confidence Interval: 1.5 – 26.7, and p<0.012). Additionally, subjects who underwent preoperative radiation were more likely to suffer from reconstructive failure (p<0.040) as well as those who require postoperative inpatient admission (p<0.034).


      BWM represents a reliable and efficacious modality in the treatment of complex scalp wounds. Patient comorbidities may not heavily influence the success of BWM to establish adequate wound coverage; however, preoperative radiation and postoperative wound infection may often lead to reconstructive failure.


      To read this article in full you will need to make a payment


        • Lutz B.S.
        Scalp and forehead reconstruction.
        Semin Plast Surg. 2010; 24: 171-180
        • Desai S.C.
        • Sand J.P.
        • Sharon J.D.
        • Branham G.
        • Nussenbaum B.
        Scalp reconstruction: an algorithmic approach and systematic review.
        JAMA Facial Plast Surg. 2015; 17: 56-66
        • Spector J.A.
        • Glat P.M.
        Hair-bearing scalp reconstruction using a dermal regeneration template and micrograft hair transplantation.
        Ann Plast Surg. 2007; 59: 63-66
        • Hoffman J.F.
        Management of scalp defects.
        Otolaryngol Clin North Am. 2001; 34: 571-582
        • Newman M.I.
        • Hanasono M.M.
        • Disa J.J.
        • Cordeiro P.G.
        • Mehrara B.J.
        Scalp reconstruction: a 15-year experience.
        Ann Plast Surg. 2004; 52: 501-506
        • Fischer J.P.
        • Sieber B.
        • Nelson J.A.
        • et al.
        A 15-year experience of complex scalp reconstruction using free tissue transfer-analysis of risk factors for complications.
        J Reconstr Microsurg. 2013; 29: 89-97
        • Lin S.J.
        • Hanasono M.M.
        • Skoracki R.J.
        Scalp and calvarial reconstruction.
        Semin Plast Surg. 2008; 22: 281-293
        • Wang H.T.
        • Erdmann D.
        • Olbrich K.C.
        • Friedman A.H.
        • Levin L.S.
        • Zenn M.R.
        Free flap reconstruction of the scalp and calvaria of major neurosurgical resections in cancer patients: lessons learned closing large, difficult wounds of the dura and skull.
        Plast Reconstr Surg. 2007; 119: 865-872
        • Serletti J.M.
        • Higgins J.P.
        • Moran S.
        • Orlando G.S.
        Factors affecting outcome in free-tissue transfer in the elderly.
        Plast Reconstr Surg. 2000; 106: 66-70
        • Watts V.
        • Attie M.D.
        • McClure S.
        Reconstruction of Complex Full-Thickness Scalp Defects After Dog-Bite Injuries Using Dermal Regeneration Template (Integra): Case Report and Literature Review.
        J Oral Maxillofac Surg. 2019; 77: 338-351
        • Moiemen N.S.
        • Staiano J.J.
        • Ojeh N.O.
        • Thway Y.
        • Frame J.D.
        Reconstructive surgery with a dermal regeneration template: clinical and histologic study.
        Plast Reconstr Surg. 2001; 108: 93-103
        • Agochukwu N.B.
        • Wong L.
        • Liau J.Y.
        Dermal Regenerative Template as a Cost-Effective Alternative for Complex Scalp Reconstruction.
        J Craniofac Surg. 2018; 29: e73-e77
        • Tufaro A.P.
        • Buck 2nd, D.W.
        • Fischer A.C.
        The use of artificial dermis in the reconstruction of oncologic surgical defects.
        Plast Reconstr Surg. 2007; 120: 638-646
        • Johnson M.B.
        • Wong A.K.
        Integra-based Reconstruction of Large Scalp Wounds: A Case Report and Systematic Review of the Literature.
        Plast Reconstr Surg Glob Open. 2016; 4 (-e1074): e1074
        • Schiavon M.
        • Francescon M.
        • Drigo D.
        • et al.
        The Use of Integra Dermal Regeneration Template Versus Flaps for Reconstruction of Full-Thickness Scalp Defects Involving the Calvaria: A Cost-Benefit Analysis.
        Aesthetic Plast Surg. 2016; 40: 901-907
        • Magnoni C.
        • de Santis G.
        • Fraccalvieri M.
        • et al.
        Integra in Scalp Reconstruction After Tumor Excision: Recommendations From a Multidisciplinary Advisory Board.
        J Craniofac Surg. 2019; 30: 2416-2420
        • Singh M.
        • Bui C.J.
        • St-Hilaire H.
        Reconstruction of complex aplasia cutis congenita.
        J Craniofac Surg. 2012; 23: e88-e90
        • Khan M.A.A.
        • Ali S.N.
        • Farid M.
        • Pancholi M.
        • Rayatt S.
        • Yap L.H.
        Use of dermal regeneration template (Integra) for reconstruction of full-thickness complex oncologic scalp defects.
        J Craniofac Surg. 2010; 21: 905-909
        • Konofaos P.
        • Kashyap A.
        • Wallace R.D.
        Total scalp reconstruction following a dog bite in a pediatric patient.
        J Craniofac Surg. 2014; 25: 1362-1364
        • Momoh A.O.
        • Lypka M.A.
        • Echo A.
        • Rizvi M.
        • Klebuc M.
        • Friedman J.D.
        Reconstruction of full-thickness calvarial defect: a role for artificial dermis.
        Ann Plast Surg. 2009; 62: 656-659
        • Abbas Khan M.A.
        • Chipp E.
        • Hardwicke J.
        • Srinivasan K.
        • Shaw S.
        • Rayatt S.
        The use of Dermal Regeneration Template (Integra) for reconstruction of a large full-thickness scalp and calvarial defect with exposed dura.
        J Plast Reconstr Aesthet Surg. 2010; 63: 2168-2171
        • Jacobson L.K.
        • Johnson M.B.
        • Dedhia R.D.
        • Niknam-Bienia S.
        • Wong A.K.
        Impaired wound healing after radiation therapy: A systematic review of pathogenesis and treatment.
        J Plast Reconstr Aesthet Surg Open. 2017; 13: 92-105
        • Miller S.H.
        • Rudolph R.
        Healing in the irradiated wound.
        Clin Plast Surg. 1990; 17: 503-508
        • Khalil H.
        • Cullen M.
        • Chambers H.
        • Carroll M.
        • Walker J.
        Elements affecting wound healing time: An evidence based analysis.
        Wound Repair Regen. 2015; 23: 550-556
        • Goltsman D.
        • Morrison K.A.
        • Ascherman J.A.
        Defining the Association between Diabetes and Plastic Surgery Outcomes: An Analysis of Nearly 40,000 Patients.
        Plast Reconstr Surg Glob Open. 2017; 5 (-e1461): e1461
        • Shakir S.
        • Messa 4th, C.A.
        • Broach R.B.
        • et al.
        Indications and Limitations of Bilayer Wound Matrix-Based Lower Extremity Reconstruction: A Multidisciplinary Case-Control Study of 191 Wounds.
        Plast Reconstr Surg. December 2019;
        • Lee L.F.
        • Porch J.v.
        • Spenler W.
        • Garner W.L.
        Integra in lower extremity reconstruction after burn injury.
        Plast Reconstr Surg. 2008; 121: 1256-1262
        • Yeong E.-K.
        • Huang H.-F.
        • Chen Y.-B.T.
        • Chen M.-T.
        The use of artificial dermis for reconstruction of full thickness scalp burn involving the calvaria.
        Burns. 2006; 32: 375-379
        • de Haas L.E.M.
        • Gardien K.L.M.
        • van Trier A.J.M.
        • Vloemans A.F.P.M.
        • Buis D.R.
        The Use of Integra in Extensive Full-Thickness Scalp Burn Involving the Skull in a Child.
        J Craniofac Surg. 2019; 30: 888-890
        • Singer M.
        • Korsh J.
        • Predun W.
        • et al.
        A novel use of integraTM bilayer matrix wound dressing on a pediatric scalp avulsion: a case report.
        Eplasty. 2015; 15 (-e8): e8