Total scalp reconstruction with bilateral anterolateral thigh flaps

Abstract

Large scalp defects can require complicated options for reconstruction, often only achieved with free flaps. In some cases, even a single free flap may not suffice. We review the literature for options in the coverage of all reported large scalp defects, and report a unique case in which total scalp reconstruction was required. In this case, two anterolateral thigh (ALT) flaps were used to resurface a large scalp and defect, covering a total of 743 cm(2). The defect occurred after resection and radiotherapy for desmoplastic melanoma, with several failed skin grafts and local flaps and osteoradionecrosis involving both inner and outer tables of the skull. The reconstruction was achieved as a single-stage reconstruction and involved wide resection of cranium and overlying soft-tissues and reconstruction with calcium phosphate bone graft substitute, titanium mesh, and two large ALT flaps. The reconstruction was successfully achieved, with minor postoperative complications including tip necrosis of one of the flaps and wound breakdown at one of the donor sites. This is the first reported case of two large ALT flaps for scalp resurfacing and may be the largest reported scalp defect to be completely resurfaced by free flaps. The use of bilateral ALT flaps can be a viable option for the reconstruction of large and/or complicated scalp defects.

Effectiveness of small monitoring skin paddle in free muscle flap for scalp reconstruction

“…Large, subtotal scalp reconstruction can be performed via various methods, such as with anterolateral thigh flap, thoracodorsal artery perforator flap, latissimus dorsi myocutaneous flap, and free latissimus dorsi flap covered with skin graft . Free latissimus dorsi flap with skin graft is preferred for the following reasons.…”

“…Large, subtotal scalp reconstruction can be performed via various methods, such as with anterolateral thigh flap, thoracodorsal artery perforator flap, latissimus dorsi myocutaneous flap, and free latissimus dorsi flap covered with skin graft. 13,14,16,[43][44][45][46][47] Free latissimus dorsi flap with skin graft is preferred for the following reasons. First, there is no need to consider the possibility of primary closure of the donor site, allowing oncologic tumor-free resection with a sufficient safety margin.…”

Free perforator flap transfer for reconstruction of skull base defects after resection of advanced recurrent tumor

“…However, the patient may need to change position during the surgery. Double‐free flaps such as bilateral ALT flaps or a double‐free flap composed of an ALT flap and a latissmus dorsi flap are other options for the reconstruction of larger, composite scalp, and calvarial defects . Dural reconstruction methods were chosen according to the dural defect size after tumor resections and the donor site choice.…”

The Fusion of Craniofacial Reconstruction and Microsurgery

“…It is our preference to harvest this flap as a fasciocutaneous flap, as it can sustain radiation therapy and is our flap of choice for coverage of alloplastic implants. 3,9 The disadvantage of the flap is noticed in corpulent patients. The excess subcutaneous fat requires thinning of the flap at the time of inset and/or liposuction as a secondary procedure.…”

“…Large defects greater than 25 cm 2 require large rotational flaps, tissue expansion, or free tissue transfer. 3,4 The most commonly used free flaps used include thoracodorsal artery-based flaps, lateral circumflex femoral artery-based flaps, radial forearm flaps, ulnar forearm flaps, and parascapular flaps. Regrettably, there are no flap options that mimic the hair-bearing nature of the scalp.…”