Reconstruction of composite oncologic scalp defects: an algorithm approach

Introduction

Scalp defects and their management were described in 1696 by Augustin Belloste (1). Since then, advances in surgical techniques have allowed the reconstruction of larger defects using different techniques. The scalp is one of the most exposed regions to solar radiation, which explains the high rate of skin tumors occurring in this area, especially cutaneous squamous cell carcinoma. Also for this reason the probability of lesions appearing on the scalp increases with age, mainly after the age of 60 years old (2).

The anatomical features of the scalp determine that repairing even small defects in this region can be challenging due to the lack of flexibility of the tissues with poor feasibility of local and regional flaps for defect repair. Another feature that differentiates the scalp is the presence of hair, which is an important consideration to be taken into account during reconstruction planning, to provide an aesthetically pleasing reconstruction.

The aim of our study is to provide an algorithm for reconstruction of scalp defects according to their size and location, patient condition and radiotherapy (RT) status, in order to facilitate the decisions of the head and neck surgeon.

Methods

A retrospective observational study was conducted on 35 patients with acquired oncologic scalp defects who underwent surgical reconstruction between 2015 and 2021 in the Department of Oral and Maxillofacial Surgery at Ramón y Cajal University Hospital. Eligible patients presented with partial or full-thickness scalp defects resulting from tumor resections and required either primary or secondary reconstruction. All surgeries were performed by the same surgical team to ensure consistency in technique and outcomes. Patient selection criteria included adult patients with confirmed oncologic scalp defects; exclusions were applied to individuals with congenital or traumatic scalp defects.

The following variables were systematically analyzed: patient sex, age, medical history with particular attention to previous or anticipated RT, defect etiology, and detailed defect characteristics such as size and location. Reconstruction methods were classified into five groups based on the approach used: primary closure, partial-thickness skin graft, local flap, regional flap, and microsurgical free flap. Specific flap types were recorded within the microsurgical category, including myofascial/myocutaneous, fasciocutaneous, and osteomyocutaneous flaps, to identify any correlation between flap type and patient outcomes. Both early and late postoperative complications were documented, including wound infection, dehiscence, flap loss, and mortality.

An algorithm for scalp reconstruction was developed based on observed outcomes, defect characteristics, and surgical factors such as cranial bone involvement and RT status. Important clinical considerations, such as prior RT exposure, cranial infiltration, and patient body mass index (BMI), were integral to algorithm design, aiming to optimize patient-specific reconstructive decisions.

Statistical analysis

Descriptive statistical analysis was performed to summarize demographic and clinical data, providing frequencies, means, and ranges where applicable. Comparative analysis examined complication rates and outcomes across the five reconstruction types. Statistical significance in complications related to RT exposure was assessed using the chi-square test or Fisher’s exact test as appropriate. A P value of <0.05 was considered statistically significant. Microsoft Excel 2010 was used for data management and analysis, ensuring the reliability and consistency of data handling.

This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. Approval by the Ethics Committee of the Ramón y Cajal Research Institution was not required, following institutional guidelines for retrospective observational studies. Informed consent was obtained from all patients prior to taking clinical photographs.

Results

Of the 35 patients with scalp defects, 26 were male (74.29%) and 9 were female (25.71%). The mean age at the time of surgery was 78.5 years (range, 42 to 93 years). Surgical excision of a malignant tumor was the most frequent etiology (31 cases, 88.6%). Scalp defects resulting from resection of benign lesions (5.7%), RT treatment (2.86%), and chronic infections sequelae (2.86%) were also operated on. Twenty-one patients had a positive biopsy for squamous cell carcinoma (60%). The remaining cases were melanoma (10%), basal cell carcinoma (6%), and other neoplasms (17.33%). Table 1 summarizes the clinical and therapeutic data of each patient.

Surgical defects were located in the frontal region in 10 patients (28.6%), temporoparietal (20%), vertex (22%), parietal (15.4%), and occipital region (14.29%). The size of the defects ranged from 1.5 to 314 cm² in diameter, with a mean size of 63.45 cm². Eight cases (22.86%) required cranial bone resection through craniotomy.

All reconstructions in our study were performed immediately after tumor resection in the same surgical procedure. We did not employ delayed reconstruction for any patient. Surgical reconstructions were performed by primary closure (5.7%), partial thickness skin grafts (14.29%), local flaps (45.7%), regional flaps (5.7%) and microvascularized flaps (28.6%). These results are summarized in Table 2. In the case of microvascular-free flap reconstruction, temporal vessels were the most frequently used recipients for anastomosis (80%). The facial vessels were used in one case (10%) and the thyroid vessels in another case (10%).

The mean hospital stay was 6.4 days. Patients who underwent microsurgical free flap reconstruction spent an average of 1.5 days in the post-surgical intensive care unit after surgery.

A histopathological study was performed after every surgical resection: surgical margins were clear in 22 patients out of the 31 patients diagnosed with malignant tumour (71%). The 9 remaining patients had a deep margin (skull bone or dura) involvement (29%). Lateral margins were clear in all patients.

One patient died (2.8%) in the postoperative period due to neurological complications. In this patient, tumor resection with margins including vertex-centered craniotomy was performed. During surgery, tumoral infiltration of the duramater was observed, with multiple venous vessels draining directly from the tumor mass into the cavernous sinus and requiring ligation for resection. No other serious postoperative complications were reported, including the need for urgent re-intervention nor life-threatening bleeding. Mild complications were reported in 20% of patients, being partial flap loss the most frequent (14.29%), with complete resolution of the defect achieved by outpatient dressings. One of the patients who underwent microsurgical free flap reconstruction presented dehiscence of the surgical wound in the donor site. Only one patient presented infection of the surgical site, which required a course of oral antibiotherapy and wound debridement, without further incidents. The rest of the patients (80%) had an uneventful evolution.

In those patients with deep margin involvement, RT was administered on the surgical field. None of the patients who received postoperative RT presented surgical related complications. Four patients included in the study had received previous RT treatment of the lesion. Three of the cases who had received preoperative RT presented partial flap loss (75%), having had an Orticochea type local flap, a pedicled trapezius flap and a latissimus dorsi free flap for reconstruction. Only one of the patients of this group (25%) had no complications. Of the patients who did not present complications, 96.29% had not received RT prior to treatment. The other complications described (surgical wound infection, donor site wound dehiscence, death) appeared in non-radiated patients (Table 3). We can conclude that preoperative RT statistically significantly increases the risk of postoperative complications (P<0.05).

During the 5-year follow-up, 2 patients (6.45%) presented local recurrence and 4 patients (12.90%) presented lymph node metastases, requiring new surgical or RT treatment. Two patients (6.45%), with squamous cell carcinoma and melanoma diagnosis respectively, presented distant metastases, at pulmonary, bone and hepatic localization. Five patients died due to pathology related to the neoplastic process, and 10 patients died during follow-up of non-oncologic reasons. Table 4 summarizes 5-year follow-up survival.

Discussion

Acquired scalp defects may be due to a variety of causes, with oncologic resection being the main cause described in the literature (2,3). Since radical resection with free margins remains the single most important curative option, the oncological surgeon must be ready to accomplish any type of reconstruction, independently of the type or size of the excision.

The main objectives in scalp reconstruction are to restore its functionality, including protection of the skull and to achieve an acceptable aesthetic result. To this end, whenever it is possible, tissue of similar characteristics should be used, limiting alopecia and scarring. When choosing the most appropriate reconstructive technique, most authors recommend taking into account the size, depth and location of the defect (3,4). Adequate repair is especially critical in composite defects of the midline scalp and cranial bone. Other studies include factors such as the history of previous RT treatment (5) or the importance of respecting the hairline for a good final result (6).

Newman et al. (6) proposed a simple, yet efficient, reconstructive guide based on the size of the defect, classifying them into small (<10 cm²), medium (10–50 cm²), and large (>50 cm²). Iblher et al. (7) developed an algorithm considering size and location of the defect but did not consider RT status or BMI. Harirah et al. (4) published a comprehensive study with most of the cases repaired with the use of local flaps or a dermal matrix, and an average defect area of 13.6 cm² (2), which is relatively small in comparison with our sample with 65 cm² (2) of average defect surface. Desai et al. (5) also proposed a comprehensive algorithm and made a thorough review of the subject, emphasizing the importance of understanding scalp anatomy and individualizing the treatment for each patient to achieve the best result.

In our algorithm, factors such as size and location of the defect, resection of the skull bone, patient’s condition, BMI and RT status are all considered in order to carefully choose the best option for each patient. Each technique and its rationale are briefly explained below:

Primary closure

Due to the lack of laxity of the aponeurotic galea, primary closure can only be achieved in small defects. Occasionally, incisions can be made in the galea to reduce tension, but it remains a reconstructive technique with limited use. It was used in 2 of the 35 cases presented, for defects of 1 to 3 cm² (2) in the frontal and occipital region. Zhang et al. (8) published their research on 12 patients in which they employed a skin-stretching device (EASApprox©) to close small to moderate scalp defects. By using minimally invasive needles to stretch the skin through multiple cycles within an allowable tension range, they effectively closed the defects with a low incidence of postoperative complications and acceptable functional results. Overall, this method presents a promising alternative that may reduce the reliance on flap and graft repairs for scalp defects.

Partial thickness skin grafts

The skin graft must be supported by a vascularized surgical undersurface, being the pericranium the preferred one by the authors. As an alternative option we cover the bone surface with a subgaleal fascia flap. Skin grafts have the advantage of being a simple surgical technique and allowing a rapid postoperative recovery. This technique results in alopecia of the reconstructed area, decreased skin thickness and different pigmentation; therefore, it should be reserved for patients with comorbidities (Figure 1).

Figure 1 Patient with cutaneous squamous cell carcinoma located in the vertex requiring oncologic resection and primary reconstruction. Rotational flap and placement of a partial thickness graft. Result 3 months after surgery.

Local flaps

Local flaps, specifically advancement, rotational, and transposition flaps, are valuable surgical techniques for reconstructing medium-sized defects, particularly in areas like the scalp. One of their significant advantages is their ability to provide an optimal aesthetic outcome, as these flaps utilize adjacent hair-bearing skin that matches the color and thickness of the surrounding tissue. This characteristic helps minimize alopecia, preserving the natural appearance of the scalp.

However, the use of local flaps is not without challenges. The primary disadvantage is the need for extensive incisions—often four to six times the length of the defect—along with substantial subgaleal dissection. The limited elasticity of the tissue necessitates careful planning to respect the hairline and maximize vascular supply, which is crucial for the flap’s viability (9) (Figures 2,3).

Figure 2 Patient with temporoparietal cutaneous squamous cell carcinoma. Defect after oncologic resection and design of a rotational flap for reconstruction.

Figure 3 Immediate (left) and 10-day post-operation (right) results after temporoparietal defect reconstruction presented in Figure 2. These images are published with the patient’s consent.

Despite these challenges, local flaps demonstrate a low complication rate, with minor issues such as infection or dehiscence being the most common, as highlighted by Newman et al. (6) (Figures 4,5). Our findings align with this, indicating that while complications may arise, they are generally manageable and do not significantly compromise the overall success of the procedure.

Figure 4 Local advancement and rotational flap, based on the pedicle of both superficial temporal arteries and occipital artery.

Figure 5 Dehiscence at the junction of the three flaps, with central partial necrosis. Satisfactory resolution by secondary intention healing.

García Sánchez et al. (10) published a variant of the Limberg flap technique, the modified double Z-rhombic flap, for treating small to medium-sized scalp defects, a method easy to design and perform, offering high patient acceptance and providing a quick solution without the need for larger flaps or skin grafts. However, caution is advised for defects larger than 50 cm², areas with atrophic skin and thin dermis.

When dealing with defects mainly located in vertex, the O-Z flap, and the Orticochea (11) technique showed to be a good option, including three or four flaps based on the pedicle of the temporal arteries and the occipital artery (Figure 5). Among the various local flap techniques, the Keystone Perforator Island Flap (KPIF) is notable for its adaptable design and reproducibility. While KPIF is popular for reconstructive procedures across many body areas, its application in scalp and forehead reconstructions is limited. To enhance the utility of KPIF in scalp and forehead defect coverage, Yoo et al. (12) presented four modified techniques based on their experience in twelve patients, aiming to improve the effectiveness of KPIF for small- to moderate-sized scalp and forehead defects, further broadening the options available scalp reconstructions.

Regional flaps

Regional flaps have limited indications, being used mainly in the reconstruction of medium and large defects in patients who are not candidates for microsurgical free flap reconstruction. They provide a large amount of vascularized tissue without needing a microanastomosis, but the final result is not the most desirable, neither functionally nor esthetically. The most frequently described in the literature are the pedicled trapezius flap and the pedicled latissimus dorsi musculocutaneous flap (9,13). In our study, the trapezius flap has been used only in the reconstruction of one occipital defect. This flap has a long pedicle and provides enough volume to cover large defects with little morbidity of the donor area. One of the most frequent complications is the partial loss of the skin paddle, as occurred in one of our patients; so care should be taken not to design the flap beyond 8–10 cm from the origin of the pedicle.

Microsurgical free flaps

Microvascular free flaps are the preferred option in medium to large defects reconstruction, and are the first choice in patients with RT history, as they provide vascularized tissue. The main disadvantages are the increased complexity and therefore the longer operating time. They produce a less aesthetic result by supplying non-hair-bearing skin of different color and thickness, with the consequent alopecia. The most frequently described free flaps for scalp reconstruction are the latissimus dorsi myocutaneous, antebrachial fasciocutaneous, anterolateral thigh (ALT) fasciocutaneous, rectus abdominis and omentum flaps (14-16). All of them have a long pedicle. In our sample, we mainly used the latissimus dorsi myocutaneous flap. Musculocutaneous flaps are specially recommended when the oncological resection includes the skull. The muscle of the flap can also be used as a vascularized wound bed for a skin graft (Figures 6,7).

Figure 6 Patient with large squamous cell carcinoma (314 cm²). Primary reconstruction with a latissimus dorsi myocutaneous flap with a split-thickness skin graft.

Figure 7 The left panel depicts the anterolateral thigh myocutaneous flap. The pedicle is anastomosed to the temporal vessels. The middle and right panels show the immediate postoperative result.

When choosing an appropriate flap, it is crucial to consider the specific scalp region affected, as vascular supply can vary significantly. For defects in the anterior scalp or forehead, the radial forearm flap is often recommended due to its thin skin and reliable vascularity. Conversely, for posterior scalp reconstructions, the latissimus dorsi myocutaneous flap is frequently utilized due to its longer pedicle and muscle component, which can be beneficial if the underlying skull is involved. In cases where the defect is adjacent to the temporoparietal area, the antebrachial fasciocutaneous flap can be a useful alternative, as it can provide the required volume and skin characteristics.

The ALT fasciocutaneous flap is particularly advantageous for larger defects across various scalp regions due to its versatility and sufficient skin paddle size. For patients with a lower BMI requiring extensive coverage, the ALT flap is optimal, offering a robust blood supply while minimizing donor site morbidity.

As for the vascular anastomosis, the temporal vessels are the most frequently used in the literature (14,16), as in our study. In case of absence of recipient vessels close to the defect, neck vessels can also be used (15). If the flap pedicle is not long enough, venous grafts, usually saphenous, can be harvested.

The immediate reconstruction approach, guided by a focus on maintaining oncological safety margins, promoted better recovery and helped prevent complications commonly seen with delayed procedures. This strategy aligns with our objective of minimizing patient morbidity while ensuring effective oncological control.

Special consideration should be taken to RT history of the area or the possibility of postoperative RT. Effects of RT on normal tissue are well known, resulting in decreased vascular supply to the tissues. For this reason, in medium and large defects, literature advocates the use of microsurgical free flaps as they provide a great amount of vascularized healthy tissue, being also the authors’ choice. The impact of RT on tissues is related to a greater number of complications: infection, surgical wound dehiscence, partial or total flap loss. In our patients, the most common complication related to preoperative RT was partial flap loss (75%), although this complication was not found after postoperative RT.

When choosing a flap, the BMI of the patient must also be taken into account. Thus, in patients who are candidates for reconstruction with a microsurgical flap, a decision can be made depending on the amount of volume needed for reconstruction: in patients with a high BMI, the use of an antebrachial fasciocutaneous arm flap may be more appropriate, while if the BMI is low and an extensive skin palette is needed, an ALT fasciocutaneous flap is an optimal option.

Other surgical options described in the literature are tissue expanders and dermal matrices (4,17). In our study, we did not include synthetic dermal matrices because our primary focus was on exploring and evaluating autologous reconstruction techniques. However, we recognize that synthetic dermal matrices play a valuable role in certain reconstructive scenarios, particularly when autologous tissue options are limited or when a simpler and quicker reconstruction is preferred. Dermal matrices function similarly to skin grafts, by providing a scaffold for cellular ingrowth and neovascularization, ultimately forming a skin-like layer that can effectively cover defects, especially when a vascularized undersurface is present. Tissue expanders are not a surgical technique of preference for the authors. It requires patient collaboration and is not an option for primary oncological reconstruction; furthermore, they should not be used in patients with a history of RT.

This is the therapeutic algorithm we propose for the reconstruction of scalp defects, taking into account size, location, radiation history, BMI and final aesthetic result (Figure 8).

Figure 8 Proposed therapeutic algorithm. BMI, body mass index; KPIF, Keystone Perforator Island Flap; RT, radiotherapy.

Conclusions

Surgical excision with clear margins is the gold standard for treatment of malignant tumors of the scalp. Due to the special characteristics of this anatomical region, reconstruction must be thoroughly planned and factors such as size, location and thickness of the defect, involvement of the skull bone, as well as history of RT or BMI must be considered. The algorithm we propose in this study aims to serve as a guide and facilitate the choice of the best option for each patient, prioritizing function, aesthetics and low morbidity.

Acknowledgments

None.

Footnote

Data Sharing Statement: Available at https://fomm.amegroups.com/article/view/10.21037/fomm-24-44/dss

Peer Review File: Available at https://fomm.amegroups.com/article/view/10.21037/fomm-24-44/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://fomm.amegroups.com/article/view/10.21037/fomm-24-44/coif). The authors have no conflicts of interest to declare

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. Approval by the Ethics Committee of the Ramón y Cajal Research Institution was not required, following institutional guidelines for retrospective observational studies. Written informed consent has been obtained from the patients prior to taking clinical photographs.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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