Microsurgical Scalp Reconstruction: An Overview of the Contemporary Approach

Abstract

Background Microsurgical scalp reconstruction has evolved immensely in the last half-century. The core concepts of microsurgical scalp reconstruction have always been to transfer soft tissue of a sufficient quality to within the defect while minimizing donor site morbidity. Refinements in scalp reconstruction consist of both improvement in reducing donor site morbidity and enhancing recipient site contour and balance. Furthermore, technical advancements and the vast experience within our field have allowed for preoperative evaluation of recipient vessels that are more favorable in proximity to the scalp. Methods In this review, we aim to describe the contemporary approach to microsurgical scalp reconstruction. This is to include the indications of choosing free flaps as well as how to select the ideal flap based on patient-oriented factors. The need for cranioplasty, recipient vessel selection, operative technique, and reoperations is also reviewed. In addition, our considerations and the nuances within each category are also described. Summary Scalp reconstructions involve the fundamental tenants of plastic surgery and demand application of these principles to each case on an individual basis and a successful reconstruction must consider all aspects, with backup options at the ready. Two workhorse free flaps, the anterolateral thigh perforator and latissimus dorsi muscles flaps, serve a primary role in the contemporary approach to microsurgical scalp reconstruction. Conclusion We hope this review can lay the foundation for which future plastic surgeons may continue to build and advance the approach to complex microsurgical scalp reconstruction.

Skull and Scalp En-Bloc Harvest Protects Calvarial Perfusion: A Cadaveric Study

“…31 This is especially true for large defects, necessitating acellular dermal matrix with or without underlying skull decortication, the latter of which requires diploic bone-based calvarial reconstruction. 32 33 Reconstruction using local flaps may not be possible in the setting of significant soft tissue loss (6–8 cm 2 ), 34 and regional flaps have a limited arc of transposition to the central scalp. 35 Further, local tissues with prior radiation, exposed hardware, or previous surgeries would instead favor microsurgical scalp reconstruction.…”

“…35 Further, local tissues with prior radiation, exposed hardware, or previous surgeries would instead favor microsurgical scalp reconstruction. 34 Free flaps, such as the myocutaneous latissimus dorsi flap, provide good coverage at the cost of donor site morbidity and a bulky construct lacking hair. 36 Muscle-only flaps require additional skin graft donor sites that produce a poor cosmetic result.…”

“…36 Though fasciocutaneous flaps are thinner and more easily contoured, donor site availability and morbidity remain limitations. 34 In practice, myocutaneous and fasciocutaneous flaps remain the mainstay for scalp reconstruction, with comparable low rates of flap loss, infection, and wound healing complications. 37 However, both approaches require adjunct calvarial reconstruction in the setting of large skull defects, posing additional risks and challenges.…”

Outcomes and Perioperative Risk Factors after Oncologic Free-Flap Scalp Reconstruction

“…12 However, some surgeons now routinely use duplex ultrasound imaging of recipient vessels as part of the surgical planning process, albeit not for arteriosclerosis. 13 Recipient vessel selection can be complex, with multiple vessel options 14 ; knowledge of the presence of arteriosclerosis may change surgical planning and choice of recipient vessels, which can improve outcomes.…”

“…not for arteriosclerosis. 13 Recipient vessel selection can be complex, with multiple vessel options; 14 knowledge of the presence of arteriosclerosis may change surgical planning and choice of recipient vessels, which can improve outcomes.…”