Microvascular Free Tissue Transfer in the Reconstruction of Scalp and Lateral Temporal Bone Defects

Department of Otolaryngology - Head & Neck Surgery, University of Washington Medical Center, Seattle, Washington 98195, USA.
The Journal of craniofacial surgery (Impact Factor: 0.68). 05/2011; 22(3):801-4. DOI: 10.1097/SCS.0b013e31820f3730
Source: PubMed


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.

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    • "These factors make wound dehiscence and partial flap loss common. These limitations have led reconstructive surgeons to frequently use free tissue transfer for these defects, leading to increased surgical time and complexity.4 "
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    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.
    Preview · Article · Aug 2014 · Journal of Neurological Surgery
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    • "When there are hostile wound conditions surrounding the primary scalp defect due to trauma, osteomyelitis, osteoradionecrosis, and removal of malignant tumors, a regional flap provides a suitable alternative to a local flap.15 Furthermore, the poor elasticity of the scalp may warrant the use of regional flaps when it proves too difficult for the surgeon to use a local flap.16,17 The most commonly used regional flaps are the trapezius, latissimus dorsi, pectoralis major, and splenius capitus flaps. "
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    ABSTRACT: Objective: Osteomyelitis of the skull is a rare condition that can lead to systemic illness, bone loss, intracranial complications, and mortality. Osteomyelitis of the skull typically presents as the boney invasion of an overlying infection of the scalp or sinuses, and it is typically treated with antibiotics and proper wound care. Surgical debridement of the affected bone in the form of a craniectomy may be initiated to stop the progression of the infection when antibiotics fail and the underlying bone becomes grossly eroded. Method: The authors present the case of a 54-year-old woman who required a total craniectomy after developing full-thickness osteomyelitis. A free omental flap along with dermal grafts and split-thickness skin grafts were utilized for soft tissue coverage. A semi-rigid helmet was used to provide durable protection to the brain. Results: Omental free flap with skin graft coverage provided this patient with durable and long-term soft tissue coverage for a total craniectomy defect, as well as the ability to regain mental status. Conclusions: Many factors must be analyzed when approaching composite defects of the scalp. Modality of treatment must be customized to the individual, and the decisions should be based on whether the defect is composed of soft tissue, bone or both, its size, etiology, and presence of a cerebral spinal fluid leak. The goals of treatment are restoration of durable soft tissue coverage, protection of vital underlying structures and control of cerebral spinal fluid leaks.
    Full-text · Article · Jul 2014 · Eplasty
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    • "Free tissue flaps have superior functional and esthetic outcome when compared with local tissue advancement flaps. Free flaps are often a better option for larger defects and for patients who have undergone previous reconstruction attempts or those requiring radiation therapy.7 "
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    ABSTRACT: Objective: Multiple options for reconstruction of scalp defects exist with local tissue advancement and free tissue transfer the mainstay of reconstruction. Over the last 12 years, our tertiary referral hospital has performed more than 150 scalp reconstructions. We reviewed our experience with large scalp defects and evaluated whether free tissue transfer is a viable first option for reconstruction. Methods: A retrospective review was conducted of all scalp reconstructions from January 1, 1999, to December 31, 2011. A cohort of patients with defects greater than 50 cm(2) were identified for a total of 64 operations; 10 free flaps, 28 local advancement flaps, and 26 skin grafts. Reoperation rates and complications were compared between groups. Results: Reoperation rate in the free flap group was 20% (2/10). Both reoperations were within the immediate postoperative period, one for microvascular thrombotic occlusion and the other for postoperative hematoma. The local tissue transfer group had a 14% reoperation rate (4/28), all for debridement of partial flap loss. The skin graft cohort had a 12% reoperation rate (3/26) for 1 complete and 2 partial skin graft failures; all required repeat grafting. Reoperation for free-flap complications did not require rehospitalization. In contrast, the skin graft and non-free flap reoperations frequently required rehospitalization. Conclusion: Though free tissue transfer has a higher occurrence of reoperation within the immediate postoperative period, completion of reconstruction usually occurs within a single hospitalization. Free tissue transfer is a feasible option, and we advocate for its use as a primary method for repairing large scalp defects.
    Full-text · Article · Feb 2014 · Eplasty
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