Introduction

Excess skin in nape or scalp area can cause many problems for the patient like:

• psychological problems

• Repeated infection

Sleeping (on the back) discomfort. The etiology of this condition is unknown and noticed to be associated with increased BMI

Discussion

Scalp reduction is another known procedure that encounters baldness and has nothing to do with the nape area. In this procedure, we address pathological skin problems in the nape/ lower scalp areas which results from obesity, local adipose hyperplasia, and retroviral treatment in HIV patients, and others).

A review of the literature did not reveal any guidelines or surgeries that have been described in this area (Nape/ Scalp for therapeutic excess skin excision). We are describing here this new surgery.

Below pictures are showing one of our patients in this work that was complaining of extreme discomfort – discharge- bad aesthetic look of his scalp. The patient requested to have surgery to improve his condition. Risks and benefits have been explained, and the patient agreed to do the surgery.

Conclusion

Nucho-scalpoplasty is a new innovative plastic surgery procedure to treat patients with excess Scalp - Nape skin that causes discomfort, aesthetic problems, and infection Figure 8.

Marking

Lower transverse incision line has been drowned in the lower scalp area and above the hairline (to hide the scar). Side marking extended till the lateral areas of the excess skin. Upper provisional marking is drawn to include most of the infected skin (will be adjusted during the surgery) Figures 1,2.

Procedure details

The procedure preferred to be done under General Anesthesia and in prone position. Incision over lower nape line is done followed by dissection upwards using Monopolar cautery in the subcutaneous plane (many septa will be found in these patients that cause these skin tethering, these septa should be dissected to have a proper lifting and nice cosmesis. Hemostasis should be done along with dissection. We paused dissection and were pulling down the upper flap as we go to check the perfect tension and where to stop (as done in abdominoplasty). Vertical excision is made to test perfect tension. Excision over the upper border is done as in Figure 4. Complete excision of skin (Figure 5). The lateral side (both sides) should stay within the hairline to make the scar hidden; we tapper it up to make sure we excise all the excess tissue with the best cosmetic results. (Figure 3). Suturing is done in 2 layers using absorbable sutures for the subcutaneous tissues and non-absorbable monofilaments sutures for the skin. Dressing is done as in (Figure 6). Follow up in the clinic is done every week and change of dressing was done daily (Figures 6,7).

Figure 1: Prone position + pre-operative marking (back).

Figure 2: Prone position + pre-operative marking (Sides).

Figure 3: initial lateral marking, flexible to be adjusted intraoperative according to tissue tension and excess.

Figure 4: Intraoperative: excision of excess tissue with ‘cut as you go’ technique to reach the perfect tension.

Figure 5: Intra-operative: after complete excision of excess tissue.

Figure 6: Postoperative: after dressing.

Figure 7: 3 weeks’ post-op: shows complete disappearance of the excess tissues with excellent smooth lifting.

Figure 8: Pre-Post Op pictures.