Reconstruction of scalp defects with free flaps in 30 cases

British Journal of Plastic Surgery (1998), 51, 186 190 1998 The British Association of Plastic Surgeons BRITISH JOURNAL OF PLASTIC SURGERY Reconstruction of scalp defects with free flaps in 30 cases B. S. Lutz, E C. Wei, H. C. Chen, C. H. Lin and C. Y. Wei Department of Plastic and Reconstructive Surgery, Chang Guns Memorial Hospital and Medical College, Taipei, Taiwan SUMMARY. 29 consecutive patients treated for reconstruction of various scalp defects with 30 free flaps were reviewed. The scalp defects resulted from accidents (13), electric.burns (4), tumour excision (8), chronic osteomyelitis (1), and osteoradionecrosis (1). Secondary reconstructions for cosmetic improvement were performed in 2 patients. The defects involved scalp with bone exposure in 21 patients, and both scalp and calvarium in 8 patients. The average extent of the defects was 130 cm 2 (23~420 cm2). Free flaps employed for reconstruction included radial forearm flaps (15), latissimus dorsi muscle flaps (10), medial arm flaps (2), juri flap (1), rectus abdominis muscle flap (1), and scapular flap (1). In 6 cases bone grafts were used for skull reconstruction. Three patients required dura repair. There were two flap failures. Donor-site morbidity was negligible. No local recurrence occurred in 7 tumour cases who are still alive. Secondary procedures (tissue expansion, debulking) were performed in 6 patients. The authors recommend selection of reconstructive options for scalp defects according to their aetiology, localisation, and duration of treatment, whereas the size of the defect does not seem to be the most important determinant. They conclude that a free flap procedure is appropriate for scalp reconstruction in trauma, osteomylitis, and osteoradionecrosis cases, and following radical resection of malignant tumours. Defects of the scalp are commonly caused by trauma and tumour resection. Other reasons include infections, congenital lesions or necrosis after irradiation for brain tumours. In cases where the pericranium is intact a split-thickness skin graft is a simple treatment since direct closure is often not possible due to the lack of elasticity of the scalp. If the periosteum is denuded or in cases with skull defect, local or free flaps are necessary for a sufficient coverage. Various local flaps based on the superficial temporal or occipital arteries 1~ and free flaps 5 14 including bone 15,t6 are available for reconstruction. Another option is the employment of tissue expanders either prior to resection in certain tumour casesf or in reconstruction of congenital lesions, 1~,19 and for secondary replacement of scar tissue or flaps. 9,18,2-22 In the era of tissue expanders which are applied increasingly with good aesthetic results, the question arises whether a free flap procedure is still an appropriate method for scalp coverage. Bearing this controversy in mind, we retrospectively studied our patients whose scalp defects were reconstructed with free flaps to evaluate the justification and efficacy of this treatment modality. Patients and methods From 1985 to 1996, 29 patients with various scalp defects were reconstructed (Table 1). There were 19 males and 10 females, ranging in age from 14 to 70 years (mean age 42.6 years). The scalp defects resulted from accidents (13), electrical burns (4), tumour excision (8), chronic osteomyelitis (1), and post-irradiation ulcer with osteoradionecrosis (1). Secondary soft tissue reconstructions for cosmetic improvement was performed in two patients. The mean extent of the scalp defect was 130 cm 2, ranging from 23 cm 2 to 420 cm 2. The defects involved scalp with bone exposure in 21 patients and both scalp and calvarium in 8 patients. Skull fractures were present in two cases. Among various free tissues utilised for reconstruction there were radial forearm flaps (15), latissimus dorsi muscle flaps (10), medial arm flaps (2), juri flap (1), rectus abdominis muscle flap (1), and scapular flap (1). In six patients bone grafts (rib, calvarium) were used for skull reconstructions. Three trauma cases required simultaneous dura repair. Superficial temporal artery and vein have been used most commonly for microanastomoses. In two patients (nos 26 and 27) either occipital artery and external jugular vein or facial artery and vein respectively were utilised for anastomoses. Vein grafts were employed in three patients. Eleven free flaps were transplanted simultaneously following tumour excision (8) or wound debridements (trauma 2, osteomyelitis 1), 11 flaps were delayed for a few days after debridement in trauma and electric burn cases, and six free flaps were secondarily employed tbr salvage procedures after failure of local pedicled flaps. Two flaps were transplanted secondarily for cosmesis. Reconstructions in the midface or neck area are not included in this study. 186

Reconstruction of scalp defects with free flaps 187 Table 1 Patient's data with 30 free flap reconstructions for scalp defects. No. Sex Age Aetiology Flap Size Special conditions Hospitalisation cm 2 days 1 m 63 Fall 2 m 63 RTA 3 m 30 Fall 4 f 15 RTA 5 m 32 RTA 6 f 25 Scalp avulsion 7 f 64 Fall 8 f 53 RTA 9 m 25 RTA 10 f 47 Scalp avulsion 11 f 24 RTA 12 f 37 Scalp avulsion 13 m 30 RTA 14 m 27 Electrical burn 15 m 16 Electrical burn 16 m 33 Electrical burn 17 m 55 Electrical burn 18 m 70 SCC 19 f 70 BCC 20 m 14 BCC 21 m 58 SCC 22 m 62 BCC 23 f 55 SCC 24 m 66 Adeno Ca. 25 m 60 Angiosarcoma 26 m 50 Ostcomylitis 27 m 48 Post-irradiation 28 m 27 Gun shot 29 f 60 Tumour excision Average 42.6 Rad. forearm* 108-14 LD-muscle 120 Local ped. flap loss 11 LD-muscle 255 Bone loss, meningitis preop 13 Juri flap 32 2 local ped. flap loss 15 Rad. forearm c* 23 Local ped. flap loss, dura repair 13 LD-muscle 300 Failure 32 Rad. forearm* 70 Local ped. flap loss 14 Rad. forearm* 120-20 Rad. forearm* 81 Skull fracture 14 LD-muscle 300-40 Med. arm flap* 84-11 LD-muscle 400 Local ped. flap loss 14 Rad. forearm* 84 Open skull fracture, dura repair 11 LD-muscle* 120 Secondary tissue expander 22 LD-muscle 208 10 LD-muscle 420-176 LD-muscle R 180 Failure Rad. forearm* 63 Local ped. flap loss 87 Rad. forearm 100-12 Rad. forearm* 81-10 Rad. forearm 56 Secondary tissue expander 7 Rad. forearm* 42 Satellite tumours, diab. mell. 37 Scapular flap 120-11 Rad. forearm R* 100-15 Rad. forearm 86 Satellite tumours, colon Ca. 17 Rad. forearm R 112 Satellite tumours 20 LD-muscle c 60 Calvarium bone loss postop 43 Rad. forearm* 80 Osteoradionecrosis, brain tumour 11 Med. arm flap c* 32 Dura repair, add. operations 21 Rect. abd. muscle* 50-12 130 R: split rib grafts; c: split calvarium grafts; *: forehead, temporal nonhairbearing area. Results In 30 free flaps performed in 29 cases, 2 complete failures occurred, both in the latissimus dorsi muscle group due to venous compromise. One failure was in a patient who also had an unsuccessful replantation of an avulsed scalp. The other failure happened in a patient with full thickness electrical burns who received bilateral latissimus dorsi muscle transplantations. Eventually both defects were covered with skin grafts placed on granulation tissue after having burred the skull. One radial forearm flap required re-exploration twice and revision of the venous anastomosis, probably due to technical reasons. Calvarial bone grafts, placed beneath the latissimus dorsi muscle flap in the patient with osteomyelitis (no. 26), had to be removed secondarily due to infection. In both patients the subsequent course was smooth. No other complications were seen in the remaining 26 free flaps. Duration of hospitalisation after free flap procedures is shown in Table 1. In 62% and 17.2% of patients it took an average 12 and 20 days respectively. It was prolonged (32-176 days) in 20.8% of patients due to complications (2), diabetes mellitus (1), and concomitant injuries that required additional treatment (3). Secondary procedures were performed in six cases including tissue expanders in two patients and debulking procedures in four patients. Of the eight tumour resection/reconstruction cases, one developed a secondary tumour close to the trans- planted free flap after 7 years and one died of his original primary tumour in the colon within 1 year. One patient died of his original brain tumour 7 years after successful reconstruction of a post-irradiation scalp necrosis. Discussion Various techniques have been described for reconstruction of acquired scalp defects.h7.19-22 Both size and depth of a defect have been recognised to be important factors dictating the need for free flap transplantations.5 z5 In the retrospective review of our patients, the aetiology of scalp defects also appeared to be important. In spite of only 130 cm 2 mean extension of defects and skull involvement in 8 patients only, free tissue transplantations in our series have been done mainly for post-traumatic reconstructions. As the aetiology of the defects varies, the selection of reconstructive options should differ. Based on our previous clinical experience, we propose to classify the scalp defects as shown in Table 2 for treatment guidance. In a small to moderate scalp defect, free tissue transplantation although usually not considered as priority, often becomes necessary. Traumatised tissue, or vascularly compromised irradiated tissue around defects imposes high risks of local flap failure as seen in 6 of our patients who eventually required free tissue transplantation for wound coverage. This supports the experiences of Robson 1 who successfully treated 6

188 British Journal of Plastic Surgery Fig. 1 Fig. 2 Figure 1--Patient no. 15. Scalpdefect after electricalburn with Figure ~Same patient; reconstructionwith latissimus dorsi burned skull. muscle flap. Fig. 3 Figure 3 Samepatient 2 years after scalp reconstruction.tissue expander to replace the flap with hair-bearing skin is planned. patients with free flaps for irradiation ulcers. In 4 of the 6 cases, attempts at local pedicled flap coverage had been unsuccessful. A free flap was therefore regarded as the primary choice in repairing these defects, whereas the size of the defect did not seem to be the most important determinant. In the case of concomitant chronic infection such as osteomyelitis, well vascularised tissue like muscle helps to overcome this process. 8,~c~2,~6 In the infected or in the case of high grade malignancy, either local pedicled flaps or free flaps can be employed for reconstruction. While free flaps achieve good aesthetic results in non-hairbearing areas, local pedicled flaps may be the better choice in hair-bearing regions. In cases which require postoperative irradiation, however, free flaps might be more reliable than local pedicled flaps. Furthermore, the skin graft at the donor site may not tolerate postoperative irradiation. When the scalp tumours are large, requiring scalp and calvarial reconstructions, free muscle flaps are the only effective reconstructive option. 5,7,1~,12,14A higher

Reconstruction of scalp defects with free flaps 189 Fig. 5 Figure 5--Same patient 2 years after reconstruction with medial arm flap and after one debulking procedure. No further corrections are required by the patient. Fig. 4 Figure 4~Patient no. 11. Scalp defect at the forehead region after traffic accident. Note concomitant contusion at the left temporal region and multiple lacerations. Table 2 Classification of scalp defects for selection of treatment modalities Scalp defects Involvement of adjacent tissue suspected Trauma Post-irradiation Associated with chronic infection - Osteomyelitis Following tumour resection - High grade malignancy Ulceration/infection - Low grade malignancy - No infection Treatment Free flap Free muscle flap Free flap/local pedicled flap Tissue expander prior to resection incidence of primary wound healing and shorter duration of hospitalisation after free flaps for reconstruction of skull base defects as compared to local flaps and local pedicled muscle flaps was recently described? Tissue expanders may be employed prior to resection of low grade scalp tumours such as basal cell carcinomas." The other role for tissue expanders is in replacement of scar tissue or even of flaps used for primary wound coverage with local skin to improve the colour and texture? '1~'~22 In case of extensive scalp loss, combined treatment of expanders and local pedicled flaps has shown satisfactory results. 1 References 1. Lesavoy MA, Dubrow TJ, Schwartz R J, Wackym PA, Eisenhauer DM, McGuire M. Management of large scalp defects with local pedicled flaps. Plast Reconstr Surg 1993; 91: 783-90. 2. Shenoy AM, Nanjundappa, Nayak UK, Bhargava AK, Naganoor IA, Vijayakumar M. Scalp flap - a utility and reconstructive option for head and neck surgeons. J Laryngol Otol 1993; 107: 324-8. 3. Cordeiro PG, Wolfe SA. The temporalis muscle flap revisited on its centennial: advantages, newer uses, and disadvantages. Plast Reconstr Surg 1996; 98: 980-7. 4. Lai CS, Lin SD, Chou CK, Tsai CW. The subgaleal-periosteal turnover flap for reconstruction of scalp defects. Ann Plast Surg 1993; 30: 267-71. 5. Neligan PC, Mulholland S, Irish J, et al. Flap selection in cranial base reconstruction. Plast Reconstr Surg 1996; 98:1 159-66. 6. Kroll SS, Baldwin BJ Head and neck reconstruction with the rectus abdominis free flap. Clin Plast Surg 1994; 21: 97-105. 7. Borah GL, Hidalgo DA, Wey PD. Reconstruction of extensive scalp defects with rectus free flaps. Ann Plast Surg 1995; 34: 281-5. 8. Koshima I, Fukuda H, Yamamoto H, Moriguchi T, Soeda S, Ohta S. Free anterolateral thigh flaps for reconstruction of head and neck defects. Plast Reconstr Surg 1993; 92: 421-8.

190 British Journal of Plastic Surgery 9. Koshima I, Inagawa K, Jitsuiki Y, Tsuda K, Mor!guchi T, Watanabe A. Scarpa's adipofascial flap for repair of wide scalp defects. Ann Plast Surg 1996; 36:88 92. 10. Robson MC, Zachary LS, Schmidt DR, Faibisoff B, Hekmatpanah J. Reconstruction of large cranial defects, in the presence of heavy radiation damage and infection utilizing tissue transferred by microvascular anastomoses. Plast Reconstr Surg 1989; 83: 438~42. l 1. Pennington DG, Stern HS, Lee KK. Free-flap reconstruction of large defects of the scalp and calvarium. Plast Reconstr Surg 1989; 83:655-61 12. Furnas H, Lineaweaver WC, Alpert BS, Buncke HJ. Scalp reconstruction by microvascular free tissue transfer. Ann Plast Surg 1990; 24: 431-44. 13. Wei FC, Tsao SB, Chang CN, Noordhoff MS. Scalp, skull, and dura reconstruction on an emergency basis. Ann Plast Surg 1987; 18: 252-6. 14. Earley MJ, Green MF, Milling MAR A critical appraisal of the use of free flaps in primary reconstruction of combined scalp and calvarial cancer defects. Br J Plast Surg 1990; 43: 283-9. 15. Hirase Y, Kojima T, Kinoshita Y, Bang HH, Sakaguchi T, Kijima M. Composite reconstruction for chest wall and scalp using multiple ribs-latissimus dorsi osteomyocutaneous flaps as pedicled and free flaps. Plast Reconstr Surg 1991; 87: 555-61. 16. Ueda K, Harashina T, Inoue T, Tanaka I, Harada T. Microsurgical scalp and skull reconstruction using a serratus anterior myo-osseous flap. Ann Plast Surg 1993; 31: 10-14. 17. Collins SAB, Swanson NA. Chronic tissue expansion. J Dermatol Surg Oncol 1993; 19:1090 8. 18. Colonna M, Cavallini M, De Angelis A, Preis FWB, Signorini M. The effects of scalp expansion on the cranial bone: a clinical, histological, and instrumental study. Ann Plast Surg 1996; 36:255 60, 19. Azzolini A, Riberti C, Cavalca D. Skin expansion in head and neck reconstructive surgery. Plast Reconstr Surg 1992; 90: 799-807. 20. Maladry D, Brabant B, Berard V, Dupuis R Mitz V. Secondary expansion of a totally replanted scalp for aesthetic adjustment. Plast Reconstr Surg 1994; 94:10524 21. McIvor NP, long MW, Berger KJ, Freeman JL. Use of tissue expansion in head and neck reconstruction. J Otolaryngol 1994; 23:46-9 22. Morselli PG, Tosti A. Tissue expansion for the surgical correction of complications caused by hair replacement fiber implants. Eur J Plast Surg 1997; 20:45 7. Acknowledgement The authors would like to express their thanks to Miss Shu-Fen Huang for her kind assistance in carrying out this study. The Authors Barbara S. Lutz MD, Microsurgical Fellow, Department of Plastic and Reconstructive Surgery Fu-Chan Wei MD, FACS, Professor and Chairman of the Department of Plastic and Reconstructive Surgery Hung-Chi Chen MD, FACS, Professor, Chief of the Microsurgery Extremity Reconstructive Center, Department of Plastic and Reconstructive Surgery Chih-Hung Lin MD, Consultant Plastic Surgeon, Trauma Center, Department of Surgery Ching-Yue Wei MD, Consultant Plastic Surgeon, Trauma Center, Department of Surgery Chang Gung Memorial Hospital & Medical College, 199 Tung Hwa North Road, Taipei, Taiwan 105. Correspondence to: Fu-Chan Wei. Received 25 July 1997. Accepted 30 January 1998.