Complex Scalp Reconstruction in Moyamoya Disease Using Distant Flap After Free Tissue Transfer Failure

Abstract

A preferred option among many surgeons for treating large defects in the head and neck area is reconstruction using autologous tissue, particularly free tissue transfer with microvascular anastomosis. However, some defects cannot be resolved with conventional microvascular techniques or algorithmic approaches. In this case study, a 55-year-old female, who previously underwent bypass surgery for Moyamoya disease, presented with a large scalp defect following surgical necrosis. After initial coverage using a free anterolateral thigh flap, partial necrosis developed, leaving a persistent 2×4 cm² defect. To resolve this, a distant thenar flap was harvested and successfully used for reconstruction. Postoperatively, the patient exhibited full recovery without complications. This case highlights the effectiveness of distant flap techniques, particularly when microvascular surgery is not feasible or has failed. The historical significance and continued applicability of distant flaps in challenging cases underscore their importance in the reconstructive armamentarium.