Facial Artery as a Recipient Vessel for Extensive Scalp Reconstruction With Free Omental Flap Without Vein Graft

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

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.

Two-stage Reconstruction of the Scalp with Facial AV Loop

We present the case of a 65-year-old woman with extensive osteoradionecrosis of the scalp and calvaria after external beam radiation therapy for follicular lymphoma. Due to the compromise of her adjacent vasculature including the superficial temporal vessels, she underwent two-stage reconstruction with the creation of an AVL (arteriovenous loop) graft utilizing her great saphenous vein. This was anastomosed to her right facial artery and vein, which was then matured. She underwent resection of the necrotic portions of calvaria and soft tissue of approximately 180 cm2, and a vascularized free latissimus dorsi muscle flap was harvested and anastomosed to her new conduit. This free muscle flap was then covered with a split-thickness skin graft harvested from her thigh. She achieved satisfactory functional and cosmetic results with minimal morbidity and without complication despite her age, multiple co-morbidities, and extensive and complex disease process.

Pre-Expanded Latissimus Dorsi Myocutaneous Flap for Total Scalp Defect Reconstruction

Scalp defects can be caused by various factors, and reconstruction options for scalp defects include skin grafts, local flaps, tissue expanders, and free flaps. However, currently, it is widely accepted that the use of free flaps is the most feasible method for extensive scalp defect reconstruction. While multiple flaps have been used to reconstruct scalp defects, the reconstruction of total scalp defects still remains challenging. Pre-expansion of free flaps offers several advantages, including increasing flap size and thinning of the tissue for better contour, and is particularly important in scalp reconstruction. This report describes the successful management of total scalp defect reconstruction that involved the entire frontal, parietal, occipital, and temporal regions using a pre-expanded latissimus dorsi myocutaneous flap in a 40-year-old female patient. Over 2 years of follow-up, the transplanted flap survived well and the patient eventually achieved excellent cosmetic appearance, with satisfactory durable coverage. She was able to wear a hairpiece and hat without any wound breakdown. Our report indicates that microsurgery using pre-expanded latissimus dorsi myocutaneous flap transfer is a reliable and safe choice for total scalp reconstruction, allowing reconstruction with a single-flap, an excellent aesthetic effect, and abrasive resistance.