Microvascular free tissue transfer in the reconstruction of scalp and lateral temporal bone defects.
ABSTRACT Defects of the scalp and lateral temporal bone (LTB) represent a unique challenge to the reconstructive surgeon. Simple reconstructive methods such as skin grafts, locoregional flaps, or tissue expanders are often not feasible owing to a myriad of reasons. Vascularized free tissue transfer coverage offers distinct advantages in managing these defects.
A retrospective case series was performed on all patients at the University of Washington Medical Center who had scalp or LTB defects reconstructed with free tissue transfer from May 1996 to July 2009. Cases were analyzed for defect characteristics, flap type, vessel selection, radiation status, dural exposure, complications, and outcomes.
A total of 68 free flap reconstructions were performed in 65 patients with scalp or LTB defects. A total of 22 resections included craniotomy, and 48 patients had preoperative or postoperative radiation. Defects ranged from 6 to 836 cm(2). All flaps (46 latissimus, 11 rectus, 4 radial forearm, 6 anterolateral thigh, and 1 omental) were transferred successfully. Vein grafts were required in 5 cases. Complications included delayed flap failure requiring secondary reconstruction, neck hematoma, venous thrombosis, skull base infection, large wound dehiscence, small wound dehiscence, donor site hematoma and seroma, and cerebrospinal fluid leak. Cosmetic results were consistent and durable.
Microvascular free tissue transfer is a safe and reliable method of reconstructing scalp and LTB defects while offering favorable cosmetic results. We favor the use of latissimus muscle-only flap with skin graft coverage for large scalp defects and rectus or anterolateral thigh free flaps for lateral temporal bone defects.
- SourceAvailable from: PubMed Central[Show abstract] [Hide abstract]
ABSTRACT: Objectives Describe the use of the supraclavicular artery flap for reconstruction of lateral skull and scalp defects. Discuss advantages and potential limitations of the supraclavicular artery flap. Design Case series. Setting Tertiary care academic medical center. Participants Patients undergoing lateral scalp and skull base resections. Main Outcome Measures Effectiveness in reconstructing lateral skull base defects and complications. Results All three patients reconstructed with the supraclavicular artery flap had excellent reconstructive outcomes. There were no flap losses, either complete or partial. There were no major complications, but one patient had a significant donor site dehiscence requiring local wound care. Referred sensation to the shoulder was alleviated by division of the sensory innervations into the flap. Conclusions The supraclavicular artery flap is an excellent option for lateral skull and scalp defects, and donor site morbidity is limited. It should be considered as an alternative to free tissue transfer.Journal of neurological surgery reports. 08/2014; 75(1):e5-e10.
- [Show abstract] [Hide abstract]
ABSTRACT: Reconstruction of large defects in the skull and scalp are a challenge for reconstructive surgeon. Several factors can influence the selection of a particular surgical method: anatomy of the defect, patient-dependent factors, surgeon preferences, etc. In unfavorable conditions such as large defects, presence of infection or previous surgery, microvascularized free flaps are considered superior to other reconstructive techniques in the recovery of craniofacial integrity. We present a male of 57 years with a major cosmetic defect on the forehead and active chronic infection of over 20 years onset reconstructed with a microvascular dual free flaps of the antero-lateral thigh, solving the infectious process with the use of healthy vascularized tissue, and the aesthetic defect by adding volume, achieving an excellent result.Revista Espanola de Cirugia Oral y Maxilofacial 09/2014; 36(3):119–123.
- [Show abstract] [Hide abstract]
ABSTRACT: Lateral temporal bone reconstruction after ablative surgery for malignancy, chronic infection, osteoradionecrosis, or trauma presents a challenge for the reconstructive surgeon. This complexity is due to the three-dimensional nature of the region, potential dural exposure, and the possible need for external surface repair. Successful reconstruction therefore requires achieving separation of the dura, obliteration of volume defect, and external cutaneous repair. There is significant institutional bias on the best method of reconstruction of these defects. In this review, the advantages and disadvantages of reconstructive options will be discussed as well as the potential pitfalls and complications. Head Neck, 2014Head & Neck 05/2014; · 2.83 Impact Factor
Microvascular Free Tissue Transfer in the
Reconstruction of Scalp and Lateral Temporal
Daniel A. O’Connell, M.Sc., M.D.,1Marita S. Teng, M.D.,2Eduardo Mendez, M.D.,1
and Neal D. Futran, M.D., D.M.D.1
Defects of the scalp and lateral temporal bone (LTB) represent a unique challenge
to the reconstructive surgeon. Simple reconstructive methods such as skin grafts, locore-
gional flaps, or tissue expanders are often not feasible due to a myriad of reasons.
Vascularized free tissue transfer coverage offers distinct advantages in managing these
defects. A retrospective case series was performed on all patients at the University of
Washington Medical Center who had scalp or LTB defects reconstructed with free tissue
transfer from May 1996 to July 2009. Cases were analyzed for defect characteristics, flap
type, vessel selection, radiation status, dural exposure, complications, and outcomes. Sixty-
eight free flaps were performed in 65 patients with scalp or LTB defects. Twenty-two
resections included craniotomy, and 48 patients had pre- or postoperative radiation.
Defects ranged from 6 to 836 cm2. All flaps (46 latissimus, 11 rectus, 4 radial forearm,
6 anterolateral thigh, and 1 omental) were transferred successfully. Vein grafts were
required in five cases. Complications included delayed flap failure requiring secondary
reconstruction, neck hematoma, venous thrombosis, skull base infection, large wound
dehiscence, small wound dehiscence, donor site hematoma and seroma, and cerebrospinal
fluid leak. Cosmetic results were consistent and durable. Microvascular free tissue transfer is
a safe, reliablemethod of reconstructing scalp and LTB defects and offers favorable cosmetic
results. We favor the use of latissimus muscle-only flap with skin graft coverage for large
scalp defects and rectus or anterolateral thigh free flaps for lateral temporal bone defects.
KEYWORDS: Scalp reconstruction, lateral temporal bone reconstruction, scalp
neoplasms, scalp defects, microvascular reconstruction, free tissue transfer
Scalp and lateral temporal bone defects may
result from tumor resection, chronic infection, osteror-
adionecrosis, trauma, burns, or congenital lesions.1,2
Reconstruction of these areas presents several unique
challenges including the need for coverage of sizable
composite defects with inelastic surrounding tissue, as
well as the required protection of nearby intracranial
contents. Reconstructive procedures are often further
1Department of Otolaryngology–Head and Neck Surgery, University
of Washington Medical Center, Seattle, Washington;2Department of
Otolaryngology–Head and Neck Surgery, Mount Sinai School of
Medicine, New York, New York.
Address for correspondence and reprint requests: Neal D. Futran,
M.D., D.M.D., Allison T. Wanamaker Professor and Chair, Depart-
ment of Otolaryngology–Head and Neck Surgery, University of
Washington, 1959 NE Pacific Street, Box 356515, Seattle, WA
98195 (e-mail: email@example.com).
Craniomaxillofac Trauma Reconstruction 2011;4:179–188. Copy-
right # 2011 by Thieme Medical Publishers, Inc., 333 Seventh
Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662.
Received: November 1, 2010. Accepted after revision: January 28,
2011. Published online: August 22, 2011.
complicated by previous surgery and/or radiation or
require planned postoperative radiation. Chronic soft
tissue infection or osteomyelitis of the calvarium may
also be an issue in these already complex cases. These
factors negatively impact on the viability of surrounding
tissue and severely limit the use of locoregional flaps for
reconstruction. Furthermore, aggressive disease requir-
ing resection of calvarial bone precludes the use of local
flaps or staged reconstructive procedures, such as tissue
expanders.2–4Finally, even after committing to recon-
struct these areas with free tissue transfer, it is often
challenging to reach donor vessels in the neck from scalp
sites near the vertex.
The specific goals of reconstructing scalp and
lateral temporal bone defects include (1) restoration of
the bony contour, (2) restoration of soft tissue thickness,
(3) epithelial coverage to the defect area, and (4) seal
intracranial contents from the nasal cavity or outside air.
From an overall reconstructive standpoint, it is impor-
tant to create a durable tissue that withstands trauma or
radiation and heals relatively quickly to allow for any
necessary adjuvant therapies to be administered in a
timely fashion.4Because of these considerations, and
the anatomic challenges facing locoregional reconstruc-
tion of this region of the body, free tissue transfer is
particularly useful, and commonly necessary, in scalp and
lateral temporal bone reconstruction.
This study reviews our institutional experience
in scalp and lateral temporal bone reconstruction over a
13-year period. Based on our results from 68 free flaps in
65 patients, we provide recommendations for the use of
microsurgical free tissue transfer in the reconstruction of
this challenging area.
MATERIALS AND METHODS
A retrospective chart review was performed on consec-
utive patients undergoing free flap reconstructions for
scalp and lateral temporal bone defects at the University
of Washington Medical Center between May 1, 1996,
and July 30, 2009. Information was obtained regarding
the patients’ age, sex, pathological diagnosis, and pre-
vious treatment. The location, size, and type of defects,
as well as the type of reconstruction, donor vessels,
perioperative complications, and clinical outcomes,
were then analyzed.
During the study period, 68 free flaps were performed in
65 patients with scalp or lateral temporal bone defects
(Table 1). Sixty-one of these reconstructions were pri-
mary, three flaps were secondary due to complications of
earlier reconstructions, four were required due to scalp
breakdown following craniotomy/craniectomy without
free tissue reconstruction.
Indications for free flap surgery were diverse:
squamous cell carcinoma (24), chronic wound/osteora-
carcinoma (8), angiosarcoma (5), melanoma (4), derma-
tosarcoma (1), gliosarcoma (1), Merkel cell carcinoma
(1) adenoid cystic carcinoma (1), adenocarcinoma (1),
angiomatosis (1), spindle cell carcinoma (1) recurrent
meningioma with calvarium involvement (1), and nerve
sheath tumor (1).
Fifty defects were located on the scalp, and 18 on
the lateral temporal bone. Twenty-one resections in-
cluded craniectomy; all calvarial reconstructions were via
calvarial bone grafts, titanium mesh, or porous poly-
ethylene implant (Porex Surgical Inc., Newnan, GA).
Thirty cases were performed on a previously radiated
field, and another 20 patients were planned for post-
operative radiation. Defect size ranged from 6 to
836 cm2, with a mean of 160.4 cm2.
All free tissue transfers were performed success-
fully; one case did have a venous thrombosis following a
neck hematoma requiring anastomotic revision, which
was subsequently successful. Another free flap failed
15 months following initial microvascular surgery secon-
dary to pedicle compromise during a flap recontouring
of free flaps: latissimus dorsi (46; see Fig. 1), rectus
abdominis (11; see Fig. 2), anterolateral thigh (6; see
Fig. 3), radial forearm (4), and omental (1). Size range of
defects based on reconstruction type were as follows:
latissimus dorsi: 110 to 836 cm2(mean 225.5 cm2);
6 to 140 cm2(mean 74.5 cm2); omental: 320 cm2. For
microvascular anastomosis, the donor arteries utilized
were superior thyroid (32), transverse cervical (14), facial
(18), lingual (2), and occipital (1). Donor veins were
comprised of external jugular (39), superior thyroid (4),
internal jugular (9), facial (10), retromandibular (2), and
transverse cervical (3). All anastomoses were performed
end-to-end save for nine end-to-side anastomosis to the
internal jugular vein. Five cases required the use of vein
grafts from the saphenous vein.
Overall, 10 major complications and 13 minor
complications occurred, representing a 14.7% major and
19.1% minor complication rate (Table 2). Of the major
Table 1Patient and Reconstruction Characteristics
No. of patients65
Age (y) 10–87 (mean, 67.5)
Sex 48 male, 17 female
No. of free flaps 68
No. of primary reconstructions65
No. of secondary reconstructions3
Follow-up (mo) 2–119
CRANIOMAXILLOFACIAL TRAUMA & RECONSTRUCTION/VOLUME 4, NUMBER 4 2011
complications, three patients had to return to the oper-
ating room. One patient had a significant wound dehis-
cence at the inferior border of the free flap, necessitating
coverage with a pectoralis major myocutaneous flap;
another patient developed a large dehiscence requiring
secondary free tissue transfer for closure. One patient
developed a neck hematoma leading to venous pedicle
thrombosis requiring surgical evacuation and venous
anastomosis revision. Another patient developed an
abdominal wound hematoma from the rectus abdominis
donor site, which was managed by surgical evacuation.
The third patient had persistent osteomyelitis with dural
exposure, eventually requiring a second free flap to
adequately cover the scalp. Finally, one patient devel-
oped cerebritis with seizures postoperatively, requiring
anticonvulsants and extended intravenous antibiotic
(CSF) cultures, but ultimately recovered without seque-
lae. The minor complications consisted of four minor
wound dehiscences, which healed with conservative
management; seven seromas and a single small hema-
toma in latissimus dorsi donor site wounds; and a single
case of postoperative delirium. These complications
represented 19.4% of the latissimus flaps in the series.
Over the follow-up period of 2 to 119 months
(mean 28.4 months; median 27 months), four late
complications of surgery occurred. Ten of the 48 patients
with malignancies were dead of disease, and three of
resection margins marked out. (B) Preauricular incision marked out for passage of free flap vascular pedicle for later
anastomosis in the neck region. (C) Vertex view of scalp following resection of lesion and margins. Note calvarial bone intact.
(D) Right muscle-only latissimus dorsi free flap (LDFF) for reconstruction of scalp defect.
An 84-year-old man with basal cell carcinoma (BCC) of the scalp. (A) Vertex scalp BCC lesion with proposed
MICROVASCULAR FREE TISSUE TRANSFER IN SCALP RECONSTRUCTION/O’CONNELL ET AL
those patients died of other causes. The remaining 38
patients with malignancies were alive and well with no
evidence of disease, and along with the 16 patients with
nonmalignant disease, had durable cosmetic results from
free tissue reconstruction.
When considering reconstruction of scalp and lateral
temporal bone defects, the usual ladder of options is
limited; this concept has been detailed in numerous
other publications.2–5First, the surrounding tissue is
very inelastic compared with other parts of the body, so
primary closure is only feasible for very small (usually
<3 cm) defects. Simpler reconstructive methods are
eliminated in large defects, or when bone has been
resected, due to the obvious need for sealing the intra-
resection of malignant disease, the use of staged proce-
the need to expediently resect the primary tumor. Tissue
expanders, however, can be utilized postoperatively to
normal scalp sutured to LDFF muscle. (F) Meshed split-thickness skin graft (STSG) placed over LDFF to reconstruct epithelial
lining of scalp. (G) Oblique view of scalp reconstruction with LDFF and STSG at 3-month postoperative follow-up. (H) Vertex
view of scalp reconstruction with LDFF and STSG at 3-month postoperative follow-up.
(Continued) (E) LDFF inset in scalp defect to reestablish soft tissue depth and contour of scalp region. Surrounding
CRANIOMAXILLOFACIAL TRAUMA & RECONSTRUCTION/VOLUME 4, NUMBER 42011
restore hair-bearing tissue to areas of reconstructed scalp
often poorly vascularized due to previous surgery or
For all of these reasons, free tissue transfer should
be considered for many cases of scalp and lateral tem-
poral bone defects. Beasley et al proposed a staging
system involving sizes of defects and some wound
characteristics for forehead and scalp defects.2In our
experience, it is difficult to define hard and fast criteria
for the use of free flap reconstruction; rather, it is
important to consider all factors, including but not
limited to defect size, quality of surrounding tissue,
and presence of exposed intracranial contents.
In this series, 43 of 50 scalp defects were recon-
structed with latissimus dorsi muscle-only free flaps
(Fig. 1); however, three radial forearm, two rectus
(Fig. 2), one omental, and one anterolateral thigh flaps
were also employed. The use of a combination of
latissimus muscle-only flap with split-thickness skin
graft for coverage of scalp defects allows maximum
pliability of tissue, large surface area reconstruction,
and creates a thickness that, after atrophy, closely ap-
proximates natural scalp6(Fig. 1). The overlying skin
graft typically heals very nicely, and the rate of wound
complications is low. Our lateral temporal bone defects
were reconstructed with nine rectus flaps (Fig. 2), five
anterolateral thigh flaps (Fig. 3), and four latissimus
flaps. Both the fasciocutaneous rectus free flap and
involvement. Left auricle and proposed resection margins marked. (B) Defect following resection of left auricle, left external
auditory canal, left lateral temporal bone resection, left middle ear ablation, and left parotidectomy. (C) Muscle-only left rectus
abdominis free flap (RAFF) for left lateral temporal bone reconstruction. (D) Inset of RAFF into left lateral temporal bone defect.
(A) A 72-year-old man with basal cell carcinoma of left external auditory canal and auricle with lateral temporal bone
MICROVASCULAR FREE TISSUE TRANSFER IN SCALP RECONSTRUCTION/O’CONNELL ET AL