A fresh wound
After an injury or tumor removal, there remains an area that cannot be stitched together at the edges.
CONDITION / HAIR
Scalp skin defects.
Defects of the scalp skin are areas where, after injury, burn, or tumor removal, skin is missing, and sometimes deeper tissues up to the skull bone. They are closed with the patient’s own tissues, and hair is restored with stretched skin or a transplant.
CONCEPTUAL VISUALIZATION- What it is
- Lack of scalp skin after injury, burn, or tumor removal.
- What the method depends on
- Size, location, depth, irradiation, hair growth line.
- What to close
- With skin from an adjacent area, an expander, or a free flap.
- hair
- Replaced with stretched skin with hair or with a graft.
01 / WHAT IS ITWhat is
What is
Scalp defect.
The skin of the hairy part of the head is dense, less mobile, and tightly stretched over the skull bones. Therefore, even a small wound here cannot always be simply stitched, and a large defect even less so.
A defect occurs after trauma, burn, bite, or when a tumor is removed. The scalp is often exposed to the sun and especially vulnerable to skin cancer; to completely remove a tumor, the surgeon takes a margin of healthy tissue. Sometimes not only the skin is lacking, but also deeper layers down to the bone.
The goal of reconstruction is to reliably close the wound and protect the bone, and then, as much as possible, restore hair and the natural growth line. Systematic reviews recommend choosing the simplest method that provides a good result.
If the tumor is still being treated, reconstruction is planned together with an oncologist, and in the case of skull bone damage — also with a neurosurgeon.
This is general information. The doctor will tell you what will suit you after the examination.
02 / SIGNSWith what
With what
apply
Situations can be very different — from a small scar to exposed bone.
Bare bone
The bone of the skull is visible at the bottom of the wound; this happens after severe injuries, burns, or removal of deep tumors.
Scar without hair
The wound has healed, but in its place there is a smooth scar where hair does not grow.
Scarring alopeciaAfter irradiation
The skin is thin, dense, heals poorly; the wound does not close for a long time.
Scalp tumor
A basal cell carcinoma or other skin cancer needs to be removed, and after that a defect will remain.
Basal cell carcinoma of the face and scalpLarge mole
A large nevus on the head, which is removed in parts or with an expander.
Nevi on the face and head03 / REASONSIt depends on what
It depends on what
reconstruction
The surgeon considers not only the size of the defect.
Size and location
Consider the size of the defect, its location, and whether the hairline will shift. There are tighter and more mobile areas on the scalp — this determines whether there is enough local skin.
The depth
In a series of 139 patients after oncological surgeries, complications were more frequent with large and deep defects.
Irradiation
After radiation therapy, tissues heal worse. On review, for medium and large defects in irradiated areas, a free flap is probably more suitable.
General condition
In the same series, complications were more frequent in people with weakened immunity, for example due to medication.
04 / SEEK MEDICAL ADVICE
When to seek medical advice?
An old defect or scar that has already healed is a planned situation and does not require urgent care. But a fresh head injury and the first weeks after surgery require attention.
103 Immediately, if after a blow to the head or with a wound:
- the person has fainted and does not regain consciousness;
- cannot keep eyes open, falls asleep;
- convulsions began;
- impaired vision or hearing;
- clear fluid flows from the ears or nose;
- blood flows from the ear or a bruise appeared behind the ear;
- there is numbness or weakness in any part of the body;
- difficulty walking, maintaining balance, speaking, or understanding speech;
- something is stuck in the wound or there is a dent on the head — do not remove the object yourself;
- cannot stop bleeding from the wound;
- the blood is gushing, bright red;
- the wound is very large or deep;
- a person fell from a height of more than 1 meter or from 5 steps;
- the head was hit at high speed, for example in a car accident;
- a bruise appeared around the eye, even though the eye was not hit;
- behavior has changed: the person has become irritable, inattentive, or indifferent to everything around;
- in a child under 1 year old, after a hit, there is a bruise, swelling, or a large wound on the head.
Do not delay a visit to the doctor:
The same day — after a head injury: feeling nauseous or vomiting, dizziness, you take blood-thinning medication, or there was alcohol or drugs at the time of the injury. Immediately - to the surgeon who operated: After surgery, if pain or swelling increases, the wound over the expander opens, the flap changes color (darkens, turns blue, or pales); if the surgeon is unavailable, go to the emergency department. The same day — the wound: The wound becomes red or purulent, fever develops, or there is generally poor well-being. As soon as possible, without waiting for the follow-up examination: A growth appears on the scalp or scar that is growing or changing color, or an area that is painful, itchy, bleeding, or covered with a crust for more than 4 weeks. Planned: Healed defect, scar without hair, uneven scalp.
05 / DIAGNOSTICSAs defined,
As defined,
what to do
- Documents
Discharge summary about the trauma or surgery, histology with conclusions about the incision edges, data about radiotherapy.
- Review
Size and depth of the defect, scars, mobility of the skin nearby, where the hair growth line passes, how much healthy skin with hair is available.
- CT
If the skull bone is involved or the defect is deep.
- Coordination with an oncologist or neurosurgeon.
Whether tumor treatment is completed, whether radiation therapy is needed, whether the bone needs to be restored.
06 / TREATMENTHow to close
How to close
defect.
Reconstruction proceeds from simple to complex: the simpler method that gives a reliable result is better. Large defects are closed in several stages, and the hair is restored at the end.
01
Local tissues
For small and medium defects.
- Suture and flaps.
- Skin with hair from an adjacent area is moved and returned to the defect. In a series of 913 reconstructions after head skin cancer removal, most defects were closed with adjacent tissues or a dermal matrix; complications occurred in 12.5%.
02
Expander
When there is a lack of skin with hair.
- How it works
- A balloon is placed under healthy skin and gradually filled over weeks or months. The skin stretches, then the balloon is removed, and the defect is covered with hair-bearing skin.
- Risks
- According to a review of data from 7,058 patients, after expanders on the head and neck, complications occurred in 8.73%; on the hairy part of the scalp — 27.3% (65 out of 238). Most often, the balloon protruded through the skin or a hematoma formed.
- Children
- Among 26 children with scalp skin defects in one clinic, the cause was burns in 65.4% and traffic accidents in 19.2%; the expander was the main method, complications occurred in 23%. In a series of 15 young children, two had slight flattening of the skull, which resolved on its own.
03
Free flaps
For large defects and exposed bone.
- What it is
- A flap from the thigh or back is transplanted to the head, sewing the vessels under a microscope. There is no hair on it — it is restored in the next stage.
- The results
- In a review of data from 112 patients over 65 years old, the flap did not take in 1.8%, complications occurred in 22.3%; age by itself did not increase the risk of flap loss. According to a meta-analysis of 28 studies, muscle and skin–fascia flaps did not differ in the frequency of flap loss.
- After removing the tumor
- In a series of 38 patients, the flap was transplanted after histology confirmed clear margins or along with bone replacement.
04
When the bone is exposed
- Matrix and vacuum
- The wound is covered with a dermal matrix, often with a vacuum dressing; when the patient's own tissue grows, the skin is transplanted. In a cohort of 158 cases, the estimated probability that the matrix on the head will remain after 2 months was 91% without radiation and 65% after it.
05
Hair restoration
- Transplantation into a scar or flap
- Blood circulation is worse in a scar, so engraftment is lower. Of 25 transplants in a scar observed for over six months, 18 were tracked: excellent result — 44.4%, good — 38.9%; often several sessions are needed.
07 / AT THE VALIKHNOVSKYI INSTITUTE
How
How
we treat it.
Defects of the scalp skin at the Dr. Valikhnovskyi Institute of Surgery are restored in the direction of 'Robotic Hair Transplantation': first the defect itself is covered, then hair is restored. The clinic is responsible for reconstruction; tumor treatment and oncological supervision are managed by an oncologist.
CLINIC SERVICE
Robotic hair transplantation
Own hair in baldness — with the ARTAS robot and manually, as well as after burns, injuries, and surgeries.
View service
What we do for this condition
- Fabric dermotension (expander) — the main method for large defects after burns, tumor removal, or cicatricial alopecia: skin with hair nearby is expanded with a balloon, and then used to cover the defect.
- Rotational and transposition flaps — a medium-sized defect is covered with hair-bearing skin moved from an adjacent area of the scalp; incisions in the galea reduce tension.
- Free flaps — for large defects with exposed skull bones, a flap of the latissimus dorsi muscle or thigh (ALT) is transplanted, sewing the vessels under a microscope.
- Osteoperforation and vacuum — if the bone is exposed, small holes are made in it, the wound is covered with a matrix and a vacuum dressing to allow tissue to grow under skin grafting.
- Hair transplantation after reconstruction — hair is transplanted into a scar or flap once the tissues have stabilized; often several sessions are needed.
Rostislav Valikhnovskyi
Plastic surgeon, candidate of medical sciences, founder of Dr. Valikhnovskyi Institute of Surgery.
How treatment works with us
- Photo onlineSend photos of the head from several angles, the discharge summary, and histology if there was a tumor.
- ConsultationExamination of the defect and surrounding skin; if necessary — CT and consultation with an oncologist or neurosurgeon.
- PlanHow to cover the defect, how many stages, and when to restore the hair.
- ReconstructionFlap, expander, or free flap — depending on the defect.
- RecoveryPostoperative check-ups; hair transplantation — when the tissues have stabilized.
08 / QUESTIONS AND ANSWERSCommon
Common
questions
Short answers. What is right for you, the doctor will tell you during the consultation.
Can you just sew up a wound on the head?
A small one — often yes. But the scalp skin is not very mobile, and a large defect cannot be closed without tension: then flaps or an expander are needed.
Will there be hair in this spot?
If the defect is closed with skin with hair, for example stretched with an expander, — yes. Free hair graft does not exist; it is restored with a transplant, and often several sessions are required.
Is the expander noticeable during stretching?
Yes, on the head, you can see a bulge that grows while the balloon is being filled. After the second surgery, it disappears.
How long will the treatment last?
A small defect is often closed in a single operation. With an expander — at least two stages with stretching in between, and a hair transplant — even later.
Is it possible to do reconstruction after radiation therapy?
Yes, but irradiated tissues heal worse, and more complex methods are often needed. This is taken into account when choosing the plan.
Is it possible for children?
Yes, a scalp expander is used in children as well. What and when is suitable for a child is decided individually.
Sources
15 sources · systematic reviews, meta-analyses, case series, and NHSshowCollapse
- Scalp reconstruction: an algorithmic approach and systematic reviewJAMA Facial Plastic Surgery, 2015doi:10.1001/jamafacial.2014.889 ↗
- Complications after oncologic scalp reconstruction: a 139-patient series and treatment algorithmThe Laryngoscope, 2014doi:10.1002/lary.24855 ↗
- Scalp Reconstruction after Mohs Cancer Excision: Lessons Learned from More Than 900 Consecutive CasesPlastic & Reconstructive Surgery, 2021doi:10.1097/PRS.0000000000007884 ↗
- Scalp Reconstruction after Malignant Tumor Resection: An Analysis and AlgorithmJournal of Neurological Surgery Part B: Skull Base, 2019doi:10.1055/s-0039-1683371 ↗
- Microsurgical scalp reconstruction in the elderly: a systematic review and pooled analysis of the current dataPlastic and Reconstructive Surgery, 2015doi:10.1097/PRS.0000000000000959 ↗
- A Comparison of Postoperative Outcomes Based on Muscle versus Fasciocutaneous Flaps in Scalp Reconstruction: A Systematic Review and Meta-analysisJournal of Reconstructive Microsurgery, 2024doi:10.1055/a-2404-2539 ↗
- Complications of tissue expansion in the head and neckHead & Neck, 2019doi:10.1002/hed.26017 ↗
- Tissue Expanders for Hair Restoration in the Scalp: Overexpansion Does MatterPlastic and Reconstructive Surgery - Global Open, 2024doi:10.1097/GOX.0000000000006222 ↗
- Scalp Reconstruction Techniques in Children With a Focus on Tissue ExpansionSage Open Pediatrics, 2025doi:10.1177/30502225251346255 ↗
- Long-Term Results in Scalp Tissue Expansion in ChildrenEuropean Journal of Pediatric Surgery, 2012doi:10.1055/s-0032-1315812 ↗
- Outcomes of Dermal Regeneration Templates in Irradiated and Nonirradiated Scalp DefectsJournal of Craniofacial Surgery, 2024doi:10.1097/SCS.0000000000010097 ↗
- Hair Follicle Transplantation on Scar TissueJournal of Craniofacial Surgery, 2013doi:10.1097/SCS.0b013e31828a78ad ↗
- Head injury and concussionNHS, 2025nhs.uk/conditions/head-injury-and-concussion ↗
- Cuts and grazesNHS, 2026nhs.uk/conditions/cuts-and-grazes ↗
- Symptoms of non-melanoma skin cancerNHS, 2026nhs.uk/conditions/non-melanoma-skin-cancer/symptoms ↗
The figures on the page are from these sources.
Scalp skin defect
after an injury or surgery?
Send photos of the head from several angles and the discharge summary. The doctor will advise how to cover the defect and whether hair can be restored.