Management of Extensive and Complex Scalp Defects in Patients of Neoplasm

Abstract

Background: Reconstruction of extensive and complex scalp defects in patients of neoplasm remains a significant challenge because of cerebrospinal fluid leak, bacterial contamination from sinus exposure, effect of radiation therapy, neoadjuvant or postoperative chemotherapy, and functional and cosmetic deformity from the size and location of the defect. In this series, we present our experience in the management of extensive defects Materials and Methods: Between 1993 and 2008, ten patients with scalp defects received reconstruction with a variety of free flaps: four free vastus lateralis muscle flaps, three anterolateral thigh flaps, three latissimus dorsi flaps with fasciocutaneous extension and one radial forearm flap. These defects had a wide spectrum of complexities including extensive multilaminar defects with exposed brain and dura, irradiation damage, infection of the wounds and central nervous systems. The flaps were used to cover the defects resulting from the radical debridement or tumor ablation with or without radiation in patients ranging from 35 to 61 years of age. Follow-up ranged from one to ten years. The patients' demographics, surgical indications, type of flaps and exposed structures, comorbidity, complications and outcomes were assessed. Fisher's exact test was used to evaluate the correlation between CSF leakage and postoperative complications and mortality. Results: All patients were referred from our neurologic surgeons after ablative surgery with or without adjuvant radiotherapy. Among the ten patients, six had a cerebrospinal fluid leak at the time of the reconstruction. Of the six patients, one had total flap loss requiring another free flap reconstruction and two had partial flap necrosis, demanding debridement and split-thickness skin grafting. Four flaps totally survived and the cerebrospinal fluid leak all resolved in the six patients. In comparison, of the four patients without a cerebrospinal fluid leak, all flaps survived. The perioperative mortality is 10% and the overall mortality is 20%. One patient died of sepsis 1.5 months later and the other one died of primary cancer 1.5 years after reconstruction. Conclusion: Although our case number is very small, our results support that free flap reconstruction is a life-saving procedure in this high-risk population and that success is possible. Comparing to fasciocutaneous flaps, muscle flaps with primary or secondary split-thickness skin grafting can provide better cosmetic result. Difficult problems, such as severe central nervous system infection, recurrent cerebrospinal fluid leaks and large irradiated wounds including osteoradionecrosis, can be managed and resolved successfully using this technique.