Microsurgical reconstruction: a more conservative method of managing large scalp defects?

Scalp reconstruction is a challenging problem requiring attention to the etiology, size, and condition of the defect to formulate an optimal reconstructive plan. Although many "conservative" options have been described even for large wounds, the use of local flaps or split-thickness skin grafts (STSG) may actually result in the need for multiple procedures, prolonged wound care, increased patient discomfort, and an unsatisfactory aesthetic result. We reviewed 37 patients who had received a total of 38 free flaps for scalp defects >or=100 cm(2) secondary to a broad range of etiologies. There were 24 males and 13 females, with a mean age of 47.4 years (range, 7 to 83 years). The mean scalp defect size was 356.2 cm(2) (range, 130 to 675 cm(2)). More than half the patients had undergone prior local flaps or STSG that had failed (n = 20; 54.1%). Latissimus dorsi muscle or myocutaneous flaps were the most commonly used free flaps in our series. Rectus abdominis muscle, scapular, radial forearm, and omental donor sites were also used. There were a total of 10 complications among 10 patients (27%). Two patients (5.4%) had major complications, and 8 patients (21.6%) had minor complications. Four of our complications (40%) were in patients who had received radiation therapy. We achieved definitive closure using free tissue transfer in 95% of patients who had previous attempts at closure using local options. These results demonstrate that free tissue transfer is a safe and highly efficient reconstructive option to manage large scalp defects under a variety of conditions. In large complex scalp wounds, especially in those patients receiving radiation, microsurgical reconstruction should be the preferred method of management.