Closures on the scalp, like those on the shins, often involve narrow wounds under significant tension. Most surgical repairs on the scalp take place on the bald scalp of older men, where years of actinic damage have contributed to skin cancer development. In such cases, the skin may be slightly atrophic, and the degree of tissue mobility is variable, with some patients demonstrating a remarkably elastic and redundant tissue reserve and others presenting with a tight scalp with minimal laxity.
Closures on the hair-bearing scalp, such as those effected after a nonmelanoma skin cancer or pilar cyst excision, often occur in areas with a thicker dermis that has not been exposed to the same degree of actinic damage, and where the ensuing atrophy has not taken place. In such cases, the benefit of working with a thicker dermis may be mitigated by the complexity of closing a wound in a hair-bearing location.
As with all closures, it is preferable to utilize a linear repair when possible. Smaller defects are easily closed in this fashion, though larger defects on the scalp may necessitate flap or graft closure. Secondary-intention healing is also, of course, an option as well, particularly for thinner defects.
It is also important to recall that there may be significant atrophy in this sun-exposed area. Even closures under minimal tension must contend with the challenges of suture placement in atrophic areas, as the tendency toward suture material tear through may be a problem even in the absence of marked tension.
The convex nature of the scalp also lends itself to unique challenges, as repairs over a convex surface have a tendency to lead to pronounced dog-ear formation even when utilizing narrow ellipses with a high length to width ratio. Specific techniques, including the dog-ear tacking suture, may be helpful in such cases.
Repairs on the scalp under moderate tension may benefit from utilizing a 3-0 absorbable suture, while those under minimal tension, such as defects created by excising a pilar cyst, can be closed with 4-0 absorbable suture. Moderately sized needles, such as the FS-2, are a reasonable choice for most scalp closures. Superficial sutures may include suture material from a 3-0 nonabsorbable suture that may be used for additional tension relief in large closures, to a 5-0 nonabsorbable suture that may be used for improving wound-edge approximation.
As in most locations, the set-back dermal suture or buried vertical mattress suture are generally the techniques of choice on the scalp. Since scalp wounds are often fairly narrow, approaches such as the percutaneous set-back dermal suture, percutaneous buried vertical mattress, or percutaneous horizontal mattress may be useful (Figure 6-5). The percutaneous set-back dermal technique may be the approach of choice as it is easy to place and has ...