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Reconstructive: Head and Neck: Original Article

Scalp Reconstruction after Mohs Cancer Excision: Lessons Learned from More Than 900 Consecutive Cases

Harirah, Muhammad M.D.; Sanniec, Kyle M.D., M.H.A.; Yates, Tyler B.A.; Harirah, Omar B.S.; Thornton, James F. M.D.

Author Information
Plastic and Reconstructive Surgery: May 2021 - Volume 147 - Issue 5 - p 1165-1175
doi: 10.1097/PRS.0000000000007884
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Abstract

Despite its large surface area of both hair-bearing and non–hair-bearing zones, the scalp is one of the most difficult parts of the body to self-inspect. Because of this and its increased likelihood of sun exposure, the risk of skin damage and skin cancers on the scalp is high. Resection of these malignancies leaves defects with a wide variety of sizes, ranging from small, subcentimeter defects, to colossal, nearly complete scalp defects.

Scalp reconstruction has long been a mainstay of plastic surgical practice, and use of time-honored techniques can commonly achieve uniformly good results. Well documented in the literature, the difficulty in scalp reconstruction lies in its relative inelasticity and paucity of available tissue for recruitment and a requirement for hair-bearing coverage.1–5 Conversely, the presence of hair-bearing skin provides the reconstructive surgeon the ability to hide significant scars under hair-bearing scalp. In addition, unique features of the scalp are its tremendous vascularity and ability to heal under tension.6

Originally, scalp defects were approached with a certain degree of trepidation because of the relative inability for skin motion, requiring the use of pericranial flaps, large rotation flaps, and free flaps. The downside to the use of these techniques is that large and morbid surgical procedures are often required, even for the reconstruction of small areas of soft-tissue loss. Although high-quality, reliable results can be achieved, these involved procedures can be risky, especially for the elderly patients and patients with numerous comorbid conditions who constitute the majority of post-Mohs skin cancer patients. Notably, the use of pericranial flaps, which are notoriously unreliable in elderly patients, especially when crossing the midline, has fallen out of favor with the advent of acellular dermal matrices.7–11

The senior author (J.F.T.) has significant experience in reconstructing Mohs cancer resections of the scalp. The data of our experience over the past 10 years of consecutive scalp reconstructions were reviewed and analyzed. This series describes the author and sole surgeon’s approach to scalp reconstruction that has significantly changed over the course of a decade, most notably with the advent of acellular dermal matrices in conjunction with color-matched split-thickness grafting. In addition, this article provides the reconstructive surgeon with the lessons learned from our experience and an algorithmic approach for reconstruction of scalp defects.

PATIENTS AND METHODS

The study was approved by the University of Texas Southwestern Institutional Review Board. A retrospective review of all patients undergoing scalp reconstruction performed by the senior author from 2007 to 2018 was conducted. Patients were included in the study if they underwent some form of scalp reconstruction after excision of a malignancy or suspected malignancy. Patients were excluded if they had scalp reconstructions but lacked enough documentation with regard to the number and timing of procedures, or if they were lost to follow-up. Of note, isolated forehead defects were excluded from collection and analysis.

Data collection for analysis included key patient demographics (e.g., age, medical history, smoking status, medications), cancer type, and defect characteristics such as size and location. The reconstructive modality chosen, use of grafts, flaps, or biological dressings was also assessed. All cases were then evaluated for complications, including but not limited to infection, hematoma formation, flap or graft loss, donor-site complications, and cancer recurrence.

RESULTS

A total of 913 scalp reconstructions were performed from June of 2007 to May of 2018 (Table 1) in 750 patients. The average patient age at the time of surgery was 62.1 years (range, 15 to 97 years). Patients had a wide range of defects, with the those involving the forehead (61 percent of cases) and the vertex (31 percent) being most common. The remaining 8 percent included defects affecting the occipital or temporal regions of the scalp. The average defect area, which was calculated by multiplying the two largest dimensions of the defect obtained by the dermatologic surgeons following their excision of the lesion, was 13.6 cm2.

Table 1. - Patient Demographics and Defect Characteristics
Characteristic Value (%)
Average age, yr. 62.1
Average no. of procedures 1.22
Defect location
 Forehead 557 (61.1)
 Vertex 286 (31.3)
 Occipital 37 (4)
 Temporal 33 (3.6)
Average defect area, cm2 13.6
Reason for procedure
 BCC 347 (46.3)
 SCC 242 (78.5)
 Melanoma 82 (11)
 Other 40 (5.4)
 Revision 28 (3.7)
 Lipoma 10 (1.3)
 Metastasis from secondary malignancy 1 (0.1)
Smoking status
 Never 489 (65.2)
 Former 200 (26.7)
 Active 61 (8.1)
Preoperative anticoagulant status
 Patient taking anticoagulants 203 (27.1)
 Baby aspirin (81 mg) 138 (18.4)
 Regular aspirin (160–325 mg) 30 (4)
 Warfarin 37 (4.9)
 ADP receptor inhibitors (i.e., clopidogrel) 10 (1.3)
 Patient not taking anticoagulants 547 (72.9)
Perioperative radiation therapy 32 (4.3)
 Preoperative radiation therapy 25 (3.3)
 Postoperative radiation therapy 9 (1.3)
BCC, basal cell carcinoma; SCC, squamous cell carcinoma; ADP, adenosine diphosphate.

Almost half (n = 410) of the cases used adjacent tissue transfer or a local rotation flap, which was more predominantly chosen during the former half of the decade (Table 2). Almost one-third (n = 299) used Integra (Integra LifeSciences Corp., Princeton, N.J.), which was most commonly followed by split-thickness skin graft placement. Of the reconstructive procedures, 172 involved bone burring before placement of Integra or autologous skin graft. The next most frequent reconstructive modalities were skin graft alone, complex closure, and use of other acellular dermal matrices. Less common modalities included secondary healing and use of a free flap. Five of the cases required tissue expansion to achieve final hair-bearing coverage.

Table 2. - Reconstructive Modalities Used for Patient Defects over the Past 10 Years in This Study
Reconstructive Modality Value (%)
Integra 299 (32.8)
 Integra alone 99 (10.9)
 Integra followed by STSG 188 (20.6)
 Integra followed by FTSG 11 (1.2)
 Integra followed by STSG plus FTSG 1 (0.1)
Graft alone 85 (9.3)
 FTSG 38 (4.2)
 STSG 47 (5.2)
Local rotation flap or ATT 410 (45.0)
 Rotation flap or ATT alone 381 (41.8)
 Rotation flap or ATT plus FTSG 16 (1.8)
 Rotation flap or ATT plus STSG 14 (1.5)
Primary closure 73 (8.1)
Other dermal matrices 35 (3.8)
 ACell (ACell, Columbia, Md.) 25 (2.7)
 AlloDerm (LifeCell Corp., Branchburg. N.J.) 10 (1.1)
Bone burring 172 (18.8)
Secondary healing 8 (0.9)
Free flap 1 (0.1)
Required tissue expander 5 (0.7)
FTSG, full-thickness skin graft; STSG, split-thickness skin graft, ATT, adjacent tissue transfer.

A total of 94 complications (12.5 percent) were found (Table 3), with the most common being graft loss (n = 23), infection (n = 14), Integra loss (n = 14), and a nonhealing wound (n = 12). Other complications noted include, in terms of frequency, wound dehiscence, poor cosmetic result, flap failure, cancer recurrence, hematoma formation, and tissue expander failure. One patient died almost 3 months after their procedure because of respiratory failure secondary to cystic fibrosis, which was following bilateral lung transplantation.

Table 3. - All Complications Recorded over the Past 10 Years in Our Study
Complication Value (%)
Graft loss 21 (2.8)
 Mild 8 (1.1)
 Moderate 4 (0.5)
 Complete 9 (1.2)
Infection 14 (1.9)
Integra loss 14 (1.9)
 Complete 10 (1.3)
 Partial 4 (0.5)
Nonhealing wound 14 (1.9)
 With exposed bone 10 (1.3)
 Without exposed bone 4 (0.5)
Dehiscence 11 (1.5)
Poor cosmetic result 10 (1.3)
Flap failure 3 (0.4)
Cancer recurrence 3 (0.4)
Hematoma 2 (0.3)
Tissue expander failure 1 (0.1)
Death 1 (0.1)

Procedure Type and Complication Rate

A granular analysis of the observed complications was performed to assess for relationships between the four most common procedure types and complication rate. Using multiple “n − 1” chi-square tests of independence, the use of Integra or graft alone (i.e., full-thickness skin graft and/or split-thickness skin graft) was significantly associated with higher complication rates, compared to the use of local rotation flaps or adjacent tissue transfer [chi-square (1, n = 750) = 46.213; p < 0.001]. However, on a more granular level of comparison, the use of Integra compared to the use of local rotation flaps or adjacent tissue transfer was associated with significantly lower rates of poor cosmetic results (chi-square = 27.541; p < 0.001), infection (chi-square = 15.045; p < 0.001), and wound dehiscence (chi-square = 19.857; p < 0.001), whereas the rates of hematoma (chi-square = 1.13; p = 0.288), nonhealing wounds (chi-square = 0.102; p = 0.750), and recurrence (chi-square = 0.186; p = 0.6659) were not statistically significant (Fig. 1).

Fig. 1.
Fig. 1.:
Granular analysis comparing the breakdown of complication rate by major procedural category. ATT, adjacent tissue transfer (or local rotation flap). Asterisks represent statistically significant comparisons between complication type and procedural category.

Age and Complication Rate

A chi-square test of independence was performed to examine the relationship between age and complication rate. There was no statistically significant difference in the complication rate of patients older than 75 years versus patients younger than 75 years [chi-square (1, n = 750) = 2.684; p = 0.101] (Table 4).

Table 4. - Analysis of Key Preoperative Variables and Their Impact on Complication Rate
Comparison p
Age and complication rate
  <75 yr old vs. >75 yr old 0.101
Smoking status
 Active vs. nonactive 0.286
Anticoagulant use
 Taking vs. not taking 0.104
 Regular aspirin vs. no regular aspirin* 0.893
 ADP receptor inhibitors vs. no ADP receptor inhibitors 0.473
 Warfarin vs. no warfarin
Defect size <0.001
 Complication vs. no complication
Prior radiation therapy
 Prior radiation therapy vs. no prior radiation therapy <0.001
ADP, adenosine diphosphate.
*Regular aspirin: any dose of aspirin 160–325 mg.
Clopidogrel, ticagrelor, ticlopidine.
Statistically significant.

Smoking Status and Complication Rate

Another chi-square test was performed to examine the relationship between the patient’s smoking status and complication rate. The relation between these variables was nonsignificant [chi-square (1, n = 750) = 1.139; p = 0.286]. There was no statistically significant difference in the complication rate in active smokers versus nonactive smokers.

Anticoagulant Use and Complication Rate

Several chi-square tests were performed to examine the relationship between use of anticoagulant medication and complication rate. The relationship between these variables was nonsignificant [chi-square (1, n = 750) = 2.649; p = 0.104]. There was no statistically significant difference in complication rate in patients taking any anticoagulant medication versus those not taking anticoagulants. No significant relationships were observed when comparing nonusers versus users of specific anticoagulants such as regular aspirin (p = 0.893), adeno sine diphosphate receptor inhibitors (p = 0.473), and warfarin (p = 0.087).

Defect Size

An independent-samples t test was conducted to compare the average size of the defect in patients who developed a complication and patients who did not. There was a significant difference in defect size for those who developed a complication (mean ± SD, 23.64 ± 28.74 cm2) and those who did not (12.279 ± 18.405 cm2) [t(680) = 4.823; p < 0.001].

Previous Radiation Therapy

Another chi-square test was performed to examine the relationship between patients with and without a history of scalp radiation and complication rate. The relationship between the variables was significant [chi-square (1, n = 750) = 39.3; p < 0.001]. Previously irradiated defects demonstrated a higher complication rate compared with those that were not.

GENERAL APPROACH

In general, the assessment of a patient with a scalp defect depends on a key starting point: whether periosteum is or is not intact (Fig. 2). If the periosteum is intact and if the only endpoint requirement is soft-tissue coverage, even non–color-matched split-thickness or full-thickness skin grafting can provide adequate reconstruction. With absent periosteum and exposed cranium, the reconstruction is more difficult and requires a rotation flap, placement of Integra, or free flap coverage.

Fig. 2.
Fig. 2.:
Algorithmic approach to scalp reconstruction based on defect qualities, intended reconstructive endpoint, and patient preferences. FTSG, full-thickness skin graft; STSG, split-thickness skin graft.

The endpoint that must also be considered is whether hair-bearing scalp or non–hair-bearing scalp is required. If non–hair-bearing scalp is required and periosteum is absent, a suitable reconstructive endpoint can be reached with immediate Integra placement and later color-matched split-thickness grafting. However, if hair-bearing coverage is required, immediate split-thickness grafting or Integra placement followed by split-thickness grafting can be performed. Both procedures can be followed by either serial scar excision to restore hair-bearing coverage or tissue expansion and subsequent hair-bearing coverage. In select patients, microfollicular hair transplantation can be used subsequently for restoration of hair-bearing coverage.12

When developing the final operative plan, the central tenets of scalp reconstruction should always be considered. These include the likely operative use of a general anesthetic, the liberal use of epinephrine-containing local anesthetic for hemostasis, and the avoidance of electrocautery to maintain the viability of hair follicles and prevent later alopecia.13,14

TECHNIQUES

Primary Closure

For most defects less than 4 cm in one dimension, the majority can be closed simply, either directly or with adjunctive techniques, usually with intravenous sedation or general anesthetic. A simple preoperative “pinch test” can often be unreliable, as the scalp is relatively resistant to movement, which can underestimate the requirements or the ability to close the defect primarily. If the skin is able to be closed primarily, it can be done with sparse, deep sutures with staples for final closure. If an attempt at linear closure is made and the defect is unable to be closed, the remaining dog-ears can be rotated in to create a hatchet flap closure (Fig. 3).

Fig. 3.
Fig. 3.:
If attempts at primary closure are deemed unsuccessful, a “hatchet flap” can be designed (left). The standing flaps are then rotated inward to provide coverage (center) with the final postoperative appearance (right).

Further adjunctive techniques such as wide undermining and galeal scoring can provide additional soft-tissue redundancy to facilitate primary closure.15 As a rule of thumb, it has been our surgical practice that if the wound is able to be held together with simple staple closure, there is enough vascularity to proceed with final closure. Final closure provides ideal results for hair-bearing coverage and wound closure for defects with intact or exposed periosteum.

Large Rotation Flaps and Orticochea Flaps

For final hair-bearing coverage, large rotation flaps and orticochea flaps (triple-rotation flaps) can provide coverage for defects with up to 40 percent of exposed scalp without intact periosteum (Fig. 4). Although effective and predominant in our early surgical practice, large rotation flaps carry significant potential morbidity with regard to the need for general anesthetic, blood loss, and postoperative inpatient management. As such, these techniques are usually reserved for large scalp defects that require final hair-bearing coverage. In addition, for large scalp defects that do require hair-bearing coverage, simple non–color-matched split-thickness grafting with the eventual requirement for later tissue expansion, scar excision, and/or hair transplantation as a multistage operation is also effective.

Fig. 4.
Fig. 4.:
An example for the design of a rotation flap (left). Back-grafting can be performed for any portion of the donor site that remains under too much tension for primary closure (center). (Right) Final postoperative appearance.

Integra and Skin Grafting

For large scalp defects with absent periosteum that require soft-tissue non–hair-bearing coverage, our management has shifted dramatically over the past decade. Originally, these defects would have required large pericranial flaps, large rotation advancements flaps, or free flaps. Currently, the majority of these defects can be managed with a two-stage procedure—placement of an Integra dermal regeneration template followed by color-matched split-thickness skin grafting (Fig. 5). Both of these procedures can be performed in an outpatient setting under local or intravenous sedation and with operation times of approximately 30 to 40 minutes each.

Fig. 5.
Fig. 5.:
Yearly representation of the number of patients where Integra was used for the reconstruction of their scalp defects with the relative proportion of patients where Integra was used for reconstruction of their scalp defects.

Since its commercialization in the 1980s, the advent of the Integra dermal regeneration template mesh has greatly changed the management of patients with scalp defects.7,8,10,11,16,17 It has been able to provide safe, effective tissue coverage with good final aesthetic results in the form of a two-stage operation, most which can be performed under intravenous sedation. The mesh is simply sewn in place with opposing Monocryl (Ethicon, Inc., Somerville, N.J.) suture, and a sterile sponge bolster is stapled over it. The mesh and sponge bolster are left on for 5 to 7 days, after which the sponge bolster can be removed. After removal of the bolster, the patient is followed up with serial photographs until the Integra shows signs of incorporation. During this period while the Integra heals in, which lasts for 3 to 5 weeks, the patient is allowed to shower without specific wound care.

Once the mesh has been integrated, color-matched split-thickness skin grafting can be performed, using the posterior aspect of the hair-bearing scalp as a donor site (Fig. 6). In our practice, the scalp is a superior donor site compared to the extremities, because of its color-matched nature, thickness, ability to heal quickly, operative accessibility, donor-site camouflage, and subsequent hair growth. After the graft is harvested and applied in the usual fashion, another sterile sponge bolster is applied. The wound is covered with a stockinette cap that remains on for the next 4 to 5 days. The bolster is removed and the patient can shower again.

Fig. 6.
Fig. 6.:
Our technique for the harvest of split-thickness skin graft.

Wound defects less than 5 cm in one dimension with large areas of exposed bone without intact periosteum can be managed with application of Integra without the need for burring the bone beforehand.18 However, defects larger than this without intact periosteum require vascular ingrowth from the wound center and from the perimeter. It is our preference to use a water-cooled diamond burr to burr the outer table of the calvaria until punctate bleeding is observed before placing the Integra mesh and split-thickness skin graft as described above (Figs. 7 through 9).

Fig. 7.
Fig. 7.:
Bone burr depth to the diploic layer of the calvaria.
Fig. 8.
Fig. 8.:
An 84-year-old man following Mohs excision of stage T1a melanoma with a resultant 6.0 × 9.0-cm defect with areas of exposed bone. Mohs defect closed with Integra after bone burring (left) and color-matched split-thickness skin graft (center). Postoperative results at 9 months (right).
Fig. 9.
Fig. 9.:
A 70-year-old man with a history of recurrent basal cell carcinoma following Mohs excision of recurrent, multifocal, and invasive basal cell carcinoma (above, left), resulting in a large wound with exposed bone (above, center). Further excision because of positive margins was required, resulting in a defect measuring 11.8 × 10 cm (above, right). Exposed bone and nonintact periosteum was burred and the defect closed initially with Integra (below, left). A split-thickness skin graft harvested from the scalp was placed 5 weeks later. The patient began adjuvant radiotherapy 8 weeks after the initial operation with a total of 66 Gy applied to the target area. (Below, right) Postoperative appearance at 1 year.

Historically, the take rate of the Integra mesh used in our practice has exceeded 85 percent. For patients with no history of prior scalp radiation therapy that fail Integra, a secondary attempt at placement with adjunctive vacuum-assisted negative-pressure wound therapy will be attempted. Patients who fail for the second time are referred for traditional scalp closure procedures, including large rotation-advancement with or without back-grafting and free-flap coverage. The timing of perioperative radiation therapy for patients with scalp cancers and the use of the Integra mesh and split-thickness skin graft have also evolved at our institution. Here, our patients typically begin radiation therapy 1 week after Integra placement and grafting. The status of their wound is followed weekly throughout the duration of their radiation therapy (usually approximately 6 weeks). As mentioned above, it is not infrequent that these patients can encounter complications, most notably superficial or partial graft loss. However, these patients will rarely lose the entire Integra construct. Finally, patients who do have complete loss of the construct are referred for free flap coverage. Free flaps remain a mainstay for very large defects, possible exposed hardware, and irradiated scalps with poor vascular ingrowth that would likely fail Integra placement.19–21

DISCUSSION

Because of its large surface area and sun-exposed nature, the scalp remains a prevalent location for soft-tissue malignancies that require excision and clear margins. Combined with an increasingly aging population and expanded indications for Mohs surgery for the treatment of melanoma, there are increasing requirements for plastic surgery intervention for the repair and reconstruction of these post-Mohs defects.22–24 This retrospective review attempts to describe an algorithmic approach well supported by clinical experience for safe, effective, and reliable scalp reconstruction. Analysis of the literature reveals a good number of reviews on secondary scalp reconstruction for oncologic and nononcologic reasons.2–5,14,25–27 However, it is our belief that the size of this review and the breadth of the senior author’s (J.F.T.) practice provide further value to the proposed algorithm.

Our series also contains one of the largest subsets of patients aged 75 years or older who underwent scalp reconstruction, with a total of 179 patients. The results of our analysis indicate that scalp reconstruction is tolerated in elderly patients, with no statistically significant difference in complication rate compared with younger patients. In addition, our findings demonstrate the utility of newer reconstructive technologies such as the Integra dermal regeneration template, specifically for older patients with more comorbid conditions. These therapies allow us to mitigate the morbidity associated with larger, more tenuous flap-based procedures. Of note as well, no difference in complication rate was seen in patients taking anticoagulant medication relative to those not taking anticoagulants. In our series, there was one documented death. However, the patient died approximately 3 months after their reconstructive procedure because of respiratory failure secondary to cystic fibrosis.

Compared with other reviews that discuss scalp reconstruction, the series presented here is one of the largest and most diverse documented. Although other retrospective studies focus on specific defects and reconstructive modalities, the broad range of cases presented here demonstrate similar findings. In this study, 94 of 913 procedures (12.5 percent) had a complication. The numbers and percentages found by this study are not statistically different from those presented by others, with an average of 11.7 percent with complication rates cited as low as 5 percent and as high as 59 percent.2,5,25,26,28 In addition, others cited similar preoperative variables that were related to complications in their series including preoperative radiation therapy and defect size.

Current management techniques reflect the “traditional” management of scalp defects that rely on scalp rotation flaps. Although historically reliable, our dissatisfaction with these techniques was primarily from the standpoint of clinical management. Previously, patients presenting with large scalp defects were unable to be managed the same day, as they were frequently elderly and required general anesthesia with a concomitant preoperative evaluation and frequent admission postoperatively for observation. Use of Integra allowed for continued outpatient management with local or intravenous sedation and discharge to home. This technique evolved from simply temporizing the wound to serving as a final reconstruction, as it was found that the management could also survive postoperative radiation therapy. Furthermore, color-matched split-thickness skin grafting would allow optimization of aesthetic reconstruction—with perhaps equivalent or lower costs compared to flap-based reconstruction, particularly for larger defects.9

One of the most considerable limitations of this study is its retrospective design. Although most patients are typically seen in the clinic within 1 week after their operations, longer term follow-up is considerably more variable. This may potentially serve to underestimate or overestimate our complication rate. However, it is our impression the large case volume and the senior author’s regular and consistent experience with a wide variety of patients serve to mitigate the effects of this limitation.

CONCLUSIONS

It is recognized that operative endpoints are difficult to describe in this patient population, considering that nearly all properly performed scalp reconstructive procedures achieve suitable results and have infrequent failures. However, this article analyzes over a decade’s worth of cases performed by a single plastic surgeon and catalogues the evolution of scalp reconstruction during that time. It also considers the feasibility of different reconstructive modalities in terms of the patient’s experience, concurrent radiation therapy, blood loss, operative time, and anesthetic requirements. Overall, most reconstructive cases involving the scalp have become more of an outpatient surgical procedure that can be performed under intravenous or local sedation. Of most significant note, the use of biological agents (specifically the Integra dermal regeneration template) has increased in our practice.

CODING PERSPECTIVE

Coding perspective provided by Dr. Raymond Janevicius is intended to provide coding guidance.

  • 15120 Split-thickness autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 100 cm2 or less
  • +15121 Split-thickness autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; each additional 100 cm2
  • 15220 Full-thickness graft, free, including direct closure of donor site, scalp, arms, and/or legs; 20 cm2 or less
  • +15221 Full-thickness graft, free, including direct closure of donor site, scalp, arms, and/or legs; each additional 20 cm2, or part thereof
  • 15275 Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 cm2; first 25 cm2 or less wound surface area
  • +15276 Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 cm2; each additional 25 cm2 wound surface area, or part thereof
  • 15277 Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area greater than or equal to 100 cm2; first 100 cm2 wound surface area
  • +15278 Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area greater than or equal to 100 cm2; each additional 100 cm2 wound surface area, or part thereof
  • 15004 Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; first 100 cm2
  • +15005 Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; each additional 100 cm2, or part thereof
  • 14020 Adjacent tissue transfer or rearrangement, scalp, arms and/or legs; defect 10 cm2 or less
  • 14021 Adjacent tissue transfer or rearrangement, scalp, arms and/or legs; defect 10.1 cm2 to 30.0 cm2
  • 14301 Adjacent tissue transfer or rearrangement, any area; defect 30.1 cm2 to 60.0 cm2
  • +14302 Adjacent tissue transfer or rearrangement, any area; each additional 30.0 cm2, or part thereof
  • Skin graft reconstruction is reported by type of graft (split thickness, full thickness) and surface area grafted.
  • Integra is a “skin substitute graft” and is reported by surface area.
  • Adjacent tissue transfers are reported by total defect size (primary plus secondary).

CODING PRINCIPLES:

  • Skin substitute graft codes are reported by total surface area grafted and are reported in a bimodal fashion.
  • If the total grafted area is less than 100 cm2, codes 15275 and 15276 are reported in 25-cm2 increments (e.g., 75 cm2 grafted: codes 15275, 15276, and 15276).
  • If the total grafted area is greater than or equal to 100 cm2, codes 15277 and 15278 are reported in 100-cm2 increments (e.g., 175 cm2 grafted: codes 15277 and 15278).
  • The skin substitute graft codes have a 0-day global period. Subsequent procedure codes (e.g., skin graft codes) do not require modifier 58.

Disclosure: Dr. Janevicius ([email protected]), is the president of JCC, a firm specializing in coding consulting services for surgeons, government agencies, the insurance industry, attorneys, and other entities.

REFERENCES

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