Microsurgical Reconstruction of Extensive Oncological Scalp Defects

Abstract

Although most small to medium defects of the scalp can be covered by local flaps, large defects or complicating factors, such as a history of radiotherapy, often require a microsurgical reconstruction. Several factors need to be considered in such procedures. A sufficient preoperative planning is based on adequate imaging of the malignancy and a multi-disciplinary concept. Several flaps are available for such reconstructions, of which the latissimus dorsi and anterior-lateral thigh flaps are the most commonly used ones. In very large defects, combined flaps, such as a parascapular/latissimus dorsi flaps, can be highly useful or necessary. The most commonly used recipient vessels for microsurgical scalp reconstructions are the superficial temporal vessels, but various other feasible choices exist. If the concomitant veins are not sufficient, the jugular veins represent a safe back-up alternative but require a vessel interposition or long pedicle. Post-operative care and patient positioning can be difficult in these patients but can be facilitated by various devices. Overall, microsurgical reconstruction of large scalp defects is a feasible undertaking if the mentioned key factors are taken into account.

Keywords: calvarial defect; head; oncology; plastic surgery; reconstruction.

Figure 1

Intraoperative view of a patient with an oncological defect of the scalp. The latissimus skin paddle as well as the anatomical landmarks are marked.

Figure 2

The dissected superficial temporal vessels that will be utilized as recipient vessels.

Figure 3

After fitting of the flap. Note the skin grafted muscle surface with leaves only small gaps for the vessels.

Figure 4

Skin paddle of a latissimus dorsi free flap based on three perforator vessels 1 week after surgery.

Figure 5

Removal of the skin paddle after ligation and severing of the perforating vessels.

Figure 6

Intraoperative view after total full thickness scalp resection due to an angiosarcoma. Note the 26 cm × 26 cm sized defect and the planned parascapular flap with a size of 33 cm × 9 cm.

Figure 7

The combined latissimus/parascapular flap after its elevation on the common vascular pedicle.

Figure 8

Intraopearative view after fitting of the flaps. Note the more resilient skin cover of the parascapular flap over the occiput on which the head rests.

Figure 9

Follow up after 4 weeks.

Figure 10

Schematic drawing of the technique employed in cases of large caliber differences between recipient and flap vessels by chamfering the lumen.

Figure 11

A case of extensive squamous cell carcinoma of the scalp with infiltration of the calvarium.

Figure 12

Intraoperative view after resection of the scalp and the infiltrated calvarium.

Figure 13

The calvarial defect was closed with a custom-made methyl acrylate implant. Note the anatomical landmarks and the outline of the planned skin paddle of the parascapular flap.

Figure 14

The patient was initially positioned in a prone position. Note the extensive padding to reduce the incidence of pressure sores and the apparatus on the end of the bed that facilitates rotating the bed.

Figure 15

The same patient in a sitting position to prepare for extubation.