Reconstruction of a Scalp and Skull Defect with Free Latissimus Dorsi Myocutaneous Flap following Dermatofibrosarcoma Protuberans

Abstract

A 53-year-old male underwent more than 10 surgical treatments over 14 years, including a simple excision and local flap transfer, after recurrences of dermatofibrosarcoma protuberans of the head. Clinical results indicated that simple excision of dermatofibrosarcoma protuberans should not be performed as initial treatment. Instead, free flap transplantation, which permits a wide excision and complete reconstruction, should be the first treatment option.

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“…DFSP lesions with positive margins following resection are considered to be radioresponsive at doses of 50-60 Gy [7,20]. Taniguchi and colleagues reported no effect on the blood supply of the myocutaneous flap used for scalp reconstruction at doses of 120 gray of gamma radiation [6]. In our case the patient did not receive pre or post-operative radiation and there was no evidence of local recurrence over a 5-year follow up period.…”

“…Trignano and colleagues also reported the usefulness of a combined latissimus dorsi/serratus anterior flap with superadded rib free flap as an alternative procedure of vascularized coverage of composite tissue defects following variable lesions involving scalp or extrimities [17]. Taniguchi and colleagues used a latissimus dorsi myocutaneous flap alone as skin coverage for a scalp defect following repeated surgical excisions of recurrent DFSP but with subsequent administration of Urokinase (which was not used in our case) [6]. Other reconstructive options include the use of rotational flaps and Acellular Dermal Matrix (ADM) in scalp DFSP cases [2].…”

“…African Americans are more affected than Caucasians, but familial predisposition or hereditary patterns have not been established [3]. DFSP typically occurs in the trunk and proximal extremities rather than the head and neck [1,3,4,6]. They account for 7% of head and neck sarcomas with less than 5% of all DFSPs occurring in the scalp region [3,4].…”

“…They account for 7% of head and neck sarcomas with less than 5% of all DFSPs occurring in the scalp region [3,4]. It can be classified as a low or intermediate grade malignancy, which may invade the underlying structures causing bony erosion, dural infiltration, and even brain invasion, especially in the setting of recurrent tumors and certain fibrosarcomatous variants [3][4][5][6]. Distant spread is uncommon, but a few studies have reported metastases to bones, lungs, pancreas, or cervical lymph nodes [5][6][7][8].…”

“…However, there are conflicting opinions regarding the safety and efficacy in terms of local recurrence, tissue preservation and subsequent reconstruction outcomes [2]. Numerous studies have demonstrated multi-staged surgical excision and reconstruction for the management of scalp DFSPs reporting unfavorable outcomes in terms of local recurrences and/or wound complications [4,6,7]. Despite this, surgical intervention remains the cornerstone of treatment for DFSPs, as both radiotherapy and chemotherapy are commonly only used for recurrent, unresectable, and metastasizing lesions [5,7,9].…”