Reconstruction of a Complex Scalp Defect after the Failure of Free Flaps: Changing Plans and Strategy

Abstract

The ideal scalp reconstruction involves closure of the defect with similar hair-bearing local tissue in a single step. Various reconstructions can be used including primary closure, secondary healing, skin grafts, local flaps, and microvascular tissue transfer. A 53-year-old female patient suffered glioblastoma, which had recurred for the second time. The neurosurgeons performed radial debridement and an additional resection of the tumor, followed by reconstruction using a serratus anterior muscle flap with a split-thickness skin graft. Unfortunately, the flap became completely useless and a bilateral rotation flap was used to cover the defect. Two month later, seroma with infection was found due to recurrence of the tumor. Additional surgery was performed using multiple perforator based island flap. The patient was discharged two weeks after surgery without any complications, but two months later, the patient died. Radical surgical resection of tumor is the most important curative option, followed by functional and aesthetic reconstruction. We describe a patient with a highly malignant tumor that required multiple resections and subsequent reconstruction. Repeated recurrences of the tumor led to the failure of reconstruction and our strategy inevitably changed, from reconstruction to palliative treatment involving fast and stable wound closure for the patient's comfort.

Keywords: Perforator flap; Reconstructive surgical procedures; Scalp; Surgical flaps.

Fig. 1. Radical debridement of dead bone and infected tissue and resection of tumor resulted in dead space at posterior auricular area.

Fig. 2. Immediate postoperative view shows well-vascularized flap.

Fig. 3. Flap was detached and irrigation was performed.

Fig. 4. Schematic illustration of harvesting rotation flap and skin grafting for donor site.

Fig. 5. Two months later, wound disruption and chronic seroma was found on previous flap site. The tumor recurrence was found.

Fig. 6. Multiple perforator based island flap and rotated flap was planned. Schematic illustration shows the flap and the arterial pedicle.

Fig. 7. Immediate postoperative schematic illustration.

Fig. 8. A clinical photo shows nice contour and obliteration of dead space. Donor site was closed primarily.