Reconstruction of Complex Scalp Defects in Different Locations: Suggestions for Puzzle

Abstract

Objective: Scalp defects may occur following trauma, radiotherapy, oncologic resection, and recurrent surgeries. The hair-bearing scalp has a dual role, which consists of protecting the calvarium and contributing to aesthetic appearance. While the "reconstructive ladder" approach may be used to close small and medium-sized scalp defects, it is not the case for larger ones involving the calvarium or with a radiation therapy history. The aim of this study is to present cases operated due to complex scalp defects, analyze complications, and discuss the choice of reconstruction.

Material and methods: The study consists of 14 patients who were operated between December 2017 and August 2019 due to a complex scalp defect. Patient were evaluated according to age, gender, etiology, radiation therapy history, defect size and location, reconstruction steps, cranioplasty and duraplasty options, type of free flap, recipient artery, vein graft requirement, and complications.

Results: The mean age of patients, which consists of 11 men and three women, was 56.7 years. The etiology for scalp defects included basosquamous carcinoma, squamous cell carcinoma, giant basal cell carcinoma, atypical meningioma, glioblastoma multiforme, angiosarcoma, and anaplastic oligodendroglioma. The defect involved the full thickness of calvarium in nine cases and pericranium in five cases. Cranioplasties were made with rib graft (n=1), bone graft (n=1), and titanium mesh (n=7). Free flaps used for reconstruction were musculocutaneous latissimus dorsi (LD) (n=4), LD muscle (n=3), anterolateral thigh (ALT) (n=4), musculocutaneous ALT (n=1), vastus lateralis muscle (1), and rectus abdominis muscle (n=1). Flap loss was not observed. Complications occurred in four of the patients; include a partial graft loss, a wound dehiscence, seroma, and an unsatisfactory esthetic result.

Conclusion: Free tissue transfers rather than local flaps should be opted to reconstruct complex scalp defects, as failure of the latter, could create much greater defects, and worse consequences. There are many options for proper reconstruction, and it is essential to select the appropriate one, taking into account the comorbid conditions of each case.

Keywords: Free flaps; microsurgery; reconstruction; scalp.

Figure 1

Case 4, two-stage reconstruction. A 28-year-old female patient operated for glioblastoma multiforme. (a) Full-thickness scalp defect in the right frontoparietal region. (b) Per-operative view of the defect area after debridement. (c) Reconstruction of the defect area with the musculocutan latissimus dorsi flap, immediate postoperative view. (d) Post-operative 1^st week view of the patient. (e) Postoperative 6^th month computed tomography image. (f) Post-operative 6^th month view of the patient. (g) Computed tomography image after the second operation, bone reconstruction is seen with titanium mesh (h) 3^rd month image after the second reconstructive surgery.

Figure 2

Case 5, one-stage reconstruction. A 63-year-old male patient was operated for the left temporal squamous cell carcinoma. (a) Lateral view of the preoperative tumoral mass. (b) per-operative anterolateral thigh flap planning. (c) Musculocutaneous anterolateral thigh flap view. (d) After neck dissection and flap adaptation early post-operative view. (e) Image of the 2^nd post-operative week. (f) Image of the patient on the post-operative 6^th week.

Figure 3

Case 3, one-stage reconstruction. A 62-year-old male patient operated on for squamous cell cancer in the frontotemporoparietal region. (a) Pre-operative computed tomography shows the intracranial extension of the mass. (b) Pre-operative view of the patient. (c) Per-operative tumor resection image. (d) Reconstruction of the bone defect with titanium mesh. (e) Image of the latissimus dorsi muscle flap. (f) Anastomosis of the flap vessels with vein graft to facial artery and vein. (g) Early post-operative computed tomography image. (h) Intact skin graft is seen in the early post-operative period.

Figure 4

Case 7, two-stage reconstruction. First-stage reconstruction of a 38-year-old male patient operated for anaplastic oligodendroglioma. (a) Image of the pre-operative bone exposed defect area. (b) The view of unhealthy bone and soft tissues after debridement (c) Image of the musculocutaneous latissimus dorsi flap. (d) Early view of viable flap after anastomosis to the occipital artery and vein. (e) Post-operative 2^nd week view of the patient. (f) Post-operative 3^rd month view.