Reconstruction of scalp defects with the radial forearm free flap

Abstract

Background: Advanced and recurrent cutaneous squamous cell carcinoma of the scalp and forehead require aggressive surgical excision often resulting in complex defects requiring reconstruction. This study evaluates various microvascular free flap reconstructions in this patient population, including the rarely utilized radial forearm free flap.

Patients and methods: A retrospective review of patients undergoing free flap surgeries (n = 47) of the scalp between 1997 and 2011 were included. Patients were divided primarily into two cohorts: a new primary lesion (n = 21) or recurrence (n = 26). Factors examined include patient demographics, indication for surgery, defect, type of flap used, complications (major and minor), and outcomes.

Results: The patients were primarily male (n = 34), with a mean age of 67 years (25-91). A total of 58 microvascular free flap reconstructions were performed (radial forearm free flap: n = 28, latissimus dorsi: n = 20, rectus abdominis: n = 9, scapula: n = 1). Following reconstruction with a radial forearm free flap, duration of hospitalization was shorter (P = 0.04) and complications rates were similar (P = 0.46). Donor site selection correlated with defect area (P < 0.001), but not with the extent of skull defect (P = 0.70). Larger defect areas correlated with higher complications rates (P = 0.03) and longer hospitalization (P = 0.003). Patients were more likely to require multiple reconstructions if referred for a recurrent lesions (P = 0.01) or received prior radiation therapy (P = 0.02).

Conclusion: Advanced and recurrent malignancies of the scalp are aggressive and challenging to treat. The radial forearm free flap is an underutilized free flap in the reconstruction of complex scalp defects.

Figure 1

A 50 year old female presented with recurrent, poorly differentiated squamous cell carcinoma. A radical excision of the lesion, including removal of the outer table, was performed (A). A subfascial dissection of the radial forearm flap was performed with preservation of the radial nerve (B). A subcutaneous tunnel was created to access the temporal vessels (C). The harvested radial forearm free flap measured 6 x 12 cm (D). The radial forearm free flap was inset in the scalp over a drain using interrupted sutures (E). A split thickness skin graft harvested from the thigh was used to cover the donor site (F). Two weeks post-reconstruction the recipient and donor sites were healthy without evidence of flap or graft loss (G, H). Following radiation therapy the radial forearm free flap was well healed and maintained good contour (I)