Reconstruction of composite defects of the scalp and neurocranium—a treatment algorithm from local flaps to combined AV loop free flap reconstruction

Abstract

BackgroundReconstruction of cranial composite defects, including all layers of the scalp and the neurocranium, poses an interdisciplinary challenge. Especially after multiple previous operations and/or radiation therapy, sufficient reconstruction is often only possible using microsurgical free flap transplantation. The aim of this study was to analyze the therapy of interdisciplinary cases with composite defects including the scalp and neurocranium.MethodsFrom 2009 to 2017, 23 patients with 18 free flaps and 10 pedicled/local flaps were analyzed. First choices for free flaps were muscle flaps followed by fasciocutaneous flaps.ResultsExcept for four patients, a stable coverage could be reached in the first operation. Three of these patients received a local scalp rotation flap in the first operation and needed an additional free flap because the local flap was no longer sufficient for coverage after wound healing deficiency or tumor relapse. The superficial temporal artery or external carotid artery served as recipient vessels. In special cases, venous grafts or an arteriovenous loop (AV loop) were used as extensions for the recipient vessels.ConclusionsIn summary, an interdisciplinary approach with radical debridement of infected or necrotic tissue and the reconstruction of the dura mater are essential to reach a stable, long-lasting reconstructive result. Based on our experience, free flaps seem to be the first choice for patients after multiple previous operations and/or radiation therapy.

Scalp and Skull Reconstruction in Patients Irradiated for Tinea Capitis in Childhood: The Scalp Exchange Procedure

“…The rate of free flap failure in scalp reconstruction is reported as being 0 to 6% in most series, with an additional 6% of partial flap failure occasionally requiring an additional free or local flap for complete healing. [16][17][18][19]27 We consider the higher percentage of total flap failure in our group (12.5%) compared with the 6% cited in the literature is probably attributable to our small cohort. All of the local flaps had partial or complete flap failure.…”

Free Tissue Reconstruction of the Scalp

“…The facial/superficial thyroid/lingual and internal maxillary arteries are more robust, as are the external/internal/anterior jugular and retromandibular veins, but these vessels are also significantly farther away from the scalp and may require vein grafts to connect a free flap pedicle to the recipient vessels. 2…”

“…Free tissue transfer in the reconstruction of scalp defects is indicated for large defects not amenable to simpler reconstructive options or in which simpler options have failed, for reconstruction of previously radiated tissue that has a poor baseline quality, for patients in whom postoperative RT is planned and a more durable reconstruction is necessary, for patients with full-thickness calvarial bone loss, for patients with full-thickness soft tissue defects and absent periosteum, and for patients with chronic infection and compromise of the remaining soft tissue components. 2 Not all patients are candidates for free tissue transfer, however, either because of limited donor vessels near the scalp or a high perioperative risk status making an extended anesthetic unfavorable. For patients amenable to free tissue reconstruction, however, there are many advantages.…”

“…It can provide an immediate reconstruction of very large defects that is durable over time, resistant to the deleterious effects of RT, and cosmetically acceptable at both the donor and reconstructive sites. Further, many series have reported on free tissue transfer reconstruction of the scalp, 2,8,11,12 and, in general, flap success rates from all sources are greater than 95%, and partial or total flap loss is rare, making free flap reconstruction an excellent reconstructive option for many patients.…”

“…Large scalp defects can have any number of etiologies; neoplasms (commonly skin cancer) and trauma are the most common, but burns, infections (including osteomyelitis), and osteoradionecrosis can also cause defects in one or more layers of the scalp and underlying bone. 1,2 Reconstruction of scalp defects can be accomplished by primary closure or with local flaps in some cases, but larger defects, especially those in which the periosteum is absent, require free tissue transfer. Various methods of scalp reconstruction, as guided by the defect components and size, are presented below.…”