Lessons Learned in Scalp Reconstruction and Tailoring Free Tissue Transfer in the Elderly: A Case Series and Literature Review

Abstract

This article aims to demonstrate an individualized approach to an elderly patient requiring scalp reconstruction, to describe the methodology in flap selection, lessons learned, and report outcomes. A retrospective review of a single surgeon's experience of scalp reconstruction (E. D. R.) using free tissue transfer from 2005 to 2011, in patients older than 70 years, was completed. A total of eight patients met the inclusion criteria, five males and three females, with a mean age of 80.4 years (range, 73–92). Free tissue transfer achieved 100% soft tissue coverage. Six of the eight patients required cranioplasty. The mean size calvarial defect was 92 cm2 (range, 35–285 cm2). The mean flap size was 117.6 cm2 (range, 42–285 cm2). Free flaps included three ulnar, three anterolateral thigh, one latissimus dorsi, and one thoracodorsal perforator flap. The mean follow-up time was 18.4 months (range, 3–46 months). Donor site morbidity was minimal. Mortality was 0%. Immediate flap failure was 0%. Other complications occurred in six of the eight patients. Mean revisionary procedures were 1.25 procedures per patient. It was concluded that chronological age does not increase mortality or catastrophic flap complications; however, morbidity is increased in the elderly and revisionary surgery is likely.

Reconstruction of cranioplasty using the thoracodorsal artery perforator (TDAP) flap: A case series

“…The disadvantage of this flap is the color mismatch mainly in old male patients. To best of our knowledge, only Sosin has previously reported only a single case of TDAP flap soft‐tissue coverage in cranioplasty; we reported the largest case series (Sosin, Chaudhry, et al, ; Sosin, De la Cruz, et al, ). Taking into account all the benefits and despite few disadvantages, our experience has shown that TDAP flap may be considered as a valuable option in cranioplasty reconstruction.…”

“…Sosin already described a case of the TDAP flap for soft tissue reconstruction after cranioplasty (Sosin, Chaudhry, et al, ; Sosin, De la Cruz, et al, ), we present a case series reporting the TDAP flap in cranioplasty reconstruction.…”

“…Both of these muscular flaps are smaller compared to the LD flap and moreover they still require skin grafting on their raw surface. Among the fasciocutaneous flaps, the ALT flap is the first choice, because of its relatively constant anatomy, long pedicle length, and minimal donor site morbidity (Reddy et al, ; Sosin, Chaudhry, et al, ). The parascapular flap is often considered as an alternative to the ALT flap, but its main disadvantage is the short pedicle length.…”

“…The parascapular flap is often considered as an alternative to the ALT flap, but its main disadvantage is the short pedicle length. Also, the deep inferior epigastric perforator (DIEP) flap (Slater et al, ), the ulnar adipocutaneous flap (Sosin, Chaudhry, et al, ), and the radial forearm flap (Larrañaga et al, ) have been also described. Radial forearm free flap (RFFF) is routinely used in head and neck reconstruction because its main advantages: long pedicle, soft, and pliable tissues, and because the RFFF harvesting is technically less demanding compared to others flaps.…”

“…The most common flaps for soft‐tissue coverage after alloplastic cranioplasty are the latissimus dorsi (LD), the anterolateral thigh (ALT), the parascapular flaps (Larrañaga, Rios, Franciosi, Mazzaro, & Figari, ; Reddy et al, ; Sosin, De la Cruz, et al, ). Many other, both muscle and fasciocutaneous, flaps have been used (Bluebond‐Langner, Zamani, & Rodriguez, ; Larrañaga et al, ; Lee, Kleiber, Pelletier, Reid, & Gottlieb, ; Seitz, Adler, Odessey, Reid, & Gottlieb, ; Slater, Sosin, Rodriguez, & Bojovic, ; Sosin et al, ).…”