We have developed an innovative integrated approach, combining reverse-sequence endoscopic nipple-sparing mastectomy (R-E-NSM) with reverse-sequence endoscopic latissimus dorsi muscle flap (R-E-LDMF) harvest for breast reconstruction (BR), through a discreet axillary incision. While both techniques demonstrate clinical feasibility, a systematic comparison of patient-reported outcomes, complications, and cost-efficacy between endoscopic implant-based BR and R-E-LDMF BR remains unexplored. A prospective, two-center cohort study was conducted from July 2021 to March 2024, enrolling breast cancer patients who underwent R-E-NSM followed by either Dual-plane BR or R-E-LDMF BR. The Primary endpoint was patient-reported outcomes assessed using the BREAST-Q reconstruction module (focusing on breast satisfaction and quality of life). Others included clinical outcomes, complications, and oncological outcomes. Among 191 enrolled patients (41 R-E-LDMF vs. 150 Dual-plane), R-E-LDMF BR required longer operative times but incurred substantially lower hospitalization costs. After controlling for baseline patient characteristics, patients who underwent R-E-LDMF BR had greater satisfaction with their breasts (difference, -9.39; -16.97 to -1.80; P =0.016) at 1 year compared with patients who underwent Dual-plane BR. BREAST-Q scores showed no intergroup differences in quality of life. The R-E-LDMF group had higher rates of any and minor complications, while the major complication rates and oncological outcomes were similar between the two groups. The R-E-LDMF BR technique achieved comparable aesthetic results and major complication rates to the Dual-plane approach, while significantly reducing overall medical costs, despite higher minor complication rates. This approach represents a cost-effective alternative for patients seeking optimal aesthetic results with reduced financial burden.

This study evaluates the postoperative functional and quality-of-life outcomes associated with using the free noninnervated latissimus dorsi muscle flap in combination with transversus abdominis release (TAR) and retrorectus mesh for massive ventral hernia repair (VHR). Eighteen patients who underwent VHR were reviewed. Patients were contacted at least 2 years postoperatively and assessed using standardized patient-reported outcome measures (PROMs), including visual analog scale (VAS) for pain, Short-Form Health Survey (SF-12), Hernia-Related Quality-of-Life Survey (HerQLes), and Carolinas Comfort Scale (CCS). Data were analyzed using t tests and linear regression models. Comorbidities included diabetes (27.8%), chronic obstructive pulmonary disease (5.6%), smoking (5.6%), and immunosuppression (16.7%). The mean clinic follow-up was 8.9 months, with no flap failures or hernia recurrences. Medical complications occurred in 3 patients, and 5 patients (27.8%) experienced 8 surgical complications. Two patients died of unrelated causes. Of 16 survivors, 8 (50%) completed phone surveys at a mean follow-up of 36.8 months. Increasing age was positively correlated with Physical Component Summary-12 (PCS-12; 0.70, P < 0.05) and HerQLes scores (1.94, P < 0.05) but negatively with CCS scores (-2.40, P < 0.05). Larger abdominal wall defects were associated with lower PCS-12 (-2.31, P < 0.05) and HerQLes scores (-6.40, P < 0.05), whereas CCS scores increased with defect size (8.20, P < 0.05). Higher body mass index (BMI) was linked to lower Mental Component Summary-12 (MCS-12; -1.60, P < 0.05). Free LD flap is effective for repair of massive ventral hernias. Age positively impacted quality-of-life scores, whereas higher BMI and larger defects negatively influenced outcomes.

Background/Objectives: Free gracilis (GM) and latissimus dorsi muscle (LDM) flaps are reliable options for complex defect coverage, but long-term sensory outcomes remain underexplored. Sensory impairment, especially the loss of protective cutaneous sensation, increases the risk of injury, thermal damage, and ulceration in reconstructed areas. This study aimed to systematically assess multidimensional sensory recovery after free muscle flap (FMF) reconstruction. Methods: In a prospective single-center study, 94 patients (49 GM, 45 LDM) underwent standardized sensory testing following FMF transfer. Five modalities were evaluated: pressure detection (Semmes-Weinstein monofilaments), vibration perception, two-point discrimination (2PD), sharp–dull differentiation, and temperature differentiation. Measurements were compared to contralateral healthy skin (CHS). Subgroup analyses were performed by anatomical region (head, trunk, extremities). Results: All sensory modalities were significantly impaired in FMF compared to CHS (p < 0.0001). Mean pressure thresholds were markedly higher in FMF (248.8 g) versus CHS (46.8 g). Vibration perception scores were reduced (FMF 3.97 vs. CHS 5.31), and 2PD was significantly poorer (11.6 cm vs. 4.7 cm). Sharp–dull and thermal discrimination were largely absent in FMF (positivity rates < 20%), with 58.5% of patients demonstrating only deep pressure sensation (≥300 g). No significant differences were found between GM and LDM in most modalities, except for worse 2PD in GM. Subgroup analyses confirmed uniform deficits across all anatomical regions. Conclusions: FMFs without neurotization result in profound, persistent sensory deficits, particularly the loss of protective sensation. Clinically, fascio-cutaneous flaps with nerve coaptation should be considered in functionally critical regions. Future strategies should focus on neurotization techniques to enhance sensory recovery.

Facial paralysis is a potential complication of acoustic neuroma treatment, and hypoglossal-facial nerve anastomosis (HFA) is a well-established reconstructive option. We report a case of dynamic facial reanimation using a free latissimus dorsi (LD) muscle flap in a patient previously treated with HFA who remained unable to produce a spontaneous smile. A 64-year-old woman, 5 years postacoustic neuroma resection and subsequent HFA, presented with preserved facial tone but distressing involuntary synkinetic movements and inability to smile spontaneously. A V-shaped neurovascular LD muscle flap was harvested and innervated primarily by the contralateral facial nerve (CLFN), with end-to-side coaptation of the distal stump of the thoracodorsal nerve (TDN) to the ipsilateral masseteric nerve (ILMN). The zygomatic branch innervated by the hypoglossal nerve was selectively transected to mitigate adverse eyelid movements, and its end was coapted to the distal stump of the TDN to preserve orbicularis oculi tone. Postoperatively, the patient achieved synchronous oral commissure elevation and lower eyelid movement, effectively restoring a true spontaneous smile and a "smiling eye" appearance. To the best of our knowledge, this is the first report of CLFN-innervated LD muscle transfer for smile reanimation following HFA. This combination may offer a viable strategy to restore natural facial expressions in patients with complete facial paralysis.

A 61-year-old female patient with cleft lip and palate presented with a moderate palatal fistula and associated nasal deformity. The defect posed a surgical challenge, being too extensive for local mucosal flap closure, yet too confined to permit standard free flap insertion. Due to the restricted intraoral working space and reduced mucosal vascularity, a latissimus dorsi free muscle flap combined with the scapular bone was chosen for reconstruction. The nasal side of the fistula was closed using a hinge flap, and mucosalization of the muscle occurred spontaneously within 1 month. This novel technique successfully restored the continuity of the maxillary arch, addressed the alar base depression, and provided stable support for dentures. No recurrence was observed during the 1-year follow-up period. This case highlights the utility of a modified free flap approach for anatomically limited palatal fistulas, offering both functional rehabilitation and aesthetic improvement in complex craniofacial conditions.

OBJECTIVE:To demonstrate that the feasibility of using the da Vinci robotic XI surgical system for breast reconstruction with pectoralis major fascia instead of latissimus dorsi flaps.METHODS:A retrospective analysis was conducted on the clinical data of 33 female patients with breast cancer who were treated with robotic nipple sparing mastectomy and immediate breast reconstruction with gel implant (RNSMIBR) between September 2022 and June 2024 and met the selection criteria. The surgical techniques employed included the use of a latissimus dorsi muscle flap (LDMF) in seven cases (Group A), a LDMF without skin island in nine cases (Group B) and a pectoralis major fascia in 17 cases (Group C). The following data recorded: age, indication, body mass index, pathological type, treatment plan, operative time, complications, and postoperative aesthetic results.RESULTS:The time for unilateral RNSMIBR was (288.57 ± 108.68) minutes in group A, (272.22 ± 39.38) minutes in group B, and (88.53 ± 14.93) minutes in group C. In Group C, three patients erythematous flaps, and three patients experienced implant loss due to infection. The remaining patients expressed satisfaction with the aesthetic outcome of the procedure.CONCLUSIONS:The utilization of the pectoralis major fascia in lieu of the latissimus dorsi flap for RNSMIBR results in superior aesthetic outcomes and circumvents the potential injury to muscle tissue. Nevertheless, further investigation is required to ascertain the safety of this approach.

Objective: To investigate the clinical effects of free latissimus dorsi muscle flap harvested through small incision under the assistance of endoscopy in repairing deep wounds in limbs. Methods: This study was a retrospective observational study. From March 2015 to March 2024, 38 patients with deep wounds in limbs, who met the inclusion criteria, were admitted to Xijing Hospital of Air Force Medical University, including 26 males and 12 females, aged 19 to 64 years. The wounds were located in the lower leg in 21 cases, ankle in 9 cases, knee joint in 3 cases, and forearm in 5 cases. After debridement, the wound area required for muscle flap transplantation was 11.0 cm×9.0 cm to 28.0 cm×13.0 cm. The free latissimus dorsi muscle flaps were harvested through a small horizontal incision of 4-5 cm in length along the dermatoglyph in the armpit combined with a secondary incision of about 1 cm in length at the posterior axillary line under the assistance of endoscopy, with area of the muscle flap of 12.0 cm×10.0 cm to 29.0 cm×14.0 cm and length of vascular pedicle of 6-8 cm. The split-thickness skin grafts were harvested to cover the muscle flaps and the residual wounds. The harvesting time and the amount of blood loss during the harvesting process of the free latissimus dorsi muscle flap were recorded. The survivals of the transplanted muscle flap and skin graft, wound healing, and complications in the flap donor and recipient areas were observed after surgery. During follow-up, the appearance in the recipient area, the scar condition in the flap donor area, and the function of the upper limb on the flap donor side were observed. Results: The time for harvesting the free latissimus dorsi muscle flap was 160-200 minutes, with an average of 185 minutes. The amount of blood loss during the harvesting process of the muscle flap was 10-30 mL, with an average of 25 mL. Two patients developed complications in the recipient area after surgery. Among them, one patient experienced vascular crisis, the muscle flap recovered blood flow after emergency surgery to remove the thrombus and re-anastomosis of the vein, and ultimately the wound healed well; one patient had an infection at the edge of the muscle flap, and the wound healed after treatment such as debridement and dressing change. The transplanted muscle flaps and skin grafts completely survived in the remaining 36 patients. Two patients developed cystic effusion in the flap donor area about one week after surgery, and the flap donor area recovered well after puncture drainage and pressure bandaging treatment three weeks after surgery; the remaining patients had no complications such as incision infection or rupture in the flap donor area. Follow up for 6 to 18 months showed that the transplanted muscle flap and skin graft in the recipient area had good appearance, the scar in the donor area was concealed and mild, and the upper limb movement on the flap donor side was not restricted. Conclusions: Under the assistance of endoscopy, the free latissimus dorsi muscle flap can be harvested through a small horizontal incision along the dermatoglyph in the armpit, with small damage to the donor area, fast postoperative recovery, mild and concealed scar. It is in line with the goal of minimally invasive surgery and worthy of promotion and application.

Background: Skin and soft tissue reconstruction of the foot is a complex undertaking owing to unique challenges and expectations. A comprehensive report of various techniques and the rationale of the choices is seldom found in the literature. Aims and Objectives: To study various types of reconstructive challenges in the foot, the various techniques used to address them, and the results. Materials and Methods: A retrospective-prospective observational study of skin and soft-tissue defects treated by the authors in the preceding 5 years was done. Medical records were retrieved. Follow-ups were conducted. The nature of defects, the reconstructive modalities used, and the outcomes were studied. Results: A total of 28 cases of foot defects were studied. The most common causes were trauma and diabetic foot. Varying combinations of foot parts were involved, including plantar and dorsal surfaces. Repeated debridements and vacuum dressings were commonly used in preparation for resurfacing surgery. Peripheral angioplasty for improvement of blood flow was used in ischemic feet. Dermal regeneration templates were successful in carefully chosen difficult instances. Split-skin graft was commonly used for the dorsum of the foot. Pedicled and free microvascular flaps were used where bones, tendons, and weight-bearing soles were to be covered. Latissimus dorsi muscle flap with split-skin grafting was favored for weight-bearing sole reconstruction. At a minimum of 4 months of follow-up, all limbs were salvaged and functional. The median time for the return to the workplace was 3 months. Conclusion: Reconstruction of the foot is an evolving field. The reconstructive surgeon needs to be abreast with the newer modalities of treatment, and an evaluation of the current practices should be a continuous process.

Moebius syndrome is a rare congenital neurological disorder characterised by bilateral facial (VII) and abducens (VI) nerve palsies, resulting in facial paralysis and impaired ocular abduction. Additional cranial nerve involvement and anomalies, such as limb deformities and neurodevelopmental abnormalities, complicate its presentation. Facial reanimation using a free functional muscle transfer is the gold standard for restoring movement and improving psychosocial outcomes. This study presents over 25 years of surgical experience in facial reanimation for Moebius syndrome management. A retrospective analysis of patients with Moebius syndrome who underwent bilateral facial reanimation between 1998 and 2023 was conducted. Outcomes were assessed using a surgeon's score, independent panel scoring with the Hay's rating scale and evaluation of spontaneous smile. We describe our surgical technique, key aspects of post-operative therapy and potential pitfalls. Overall, 56 patients (30 women and 26 men) underwent facial reanimation. Among them, 49 had complete Moebius syndrome. Partial latissimus dorsi muscle flaps were used in 93% of the cases, with the masseteric nerve as the neural input (91%). Facial symmetry and function were rated as excellent (n=43) or good (n=11) in 96% of the patients. A spontaneous smile was achieved in 59% of the cases, with the best outcomes in masseteric-innervated latissimus dorsi transfers. Bilateral free functional muscle transfers are the gold standard for facial reanimation in Moebius syndrome management, yielding significant functional and aesthetic improvements, especially in children. We recommend performing bilateral facial reanimation as a single-stage procedure due to its physical and psychological benefits for this patient population.

Fat-augmented latissimus dorsi muscle flaps as a reliable technique for breast reconstruction in underweight patients: A bicentric retrospective case-control study.

Abstract Introduction The free latissimus dorsi flap for scalp or skull reconstruction, is a versatile solution for a wide range of reconstructive challenges. The latissimus dorsi muscle is a large, triangular back muscle with fibers form de 7th to the 12th thoracic vertebrae, its blood supply is delivered from the subscapular artery branch called the thoracodorsal artery. In this case the function of the remaining latissimus dorsi muscle is preserved. The posterior axillary fold is also preserved through the remaining cephalic portion of the muscle, resulting in an improved aesthetic outcome postoperatively. Preserving the posterior part of the latissimus dorsi and its innervation also improves symmetry and the contour of the back, avoiding the asymmetric back. Methods We present a 30-year-old male patient with 5% electrical burn of the skull with temporal, parietal and right occipital involvement, with third degree burn and bone exposure in these areas. He suffered contact of the temporal area of the head with a high voltage cable, losing consciousness and without apparent cranioencephalic trauma; however, with loss of consciousness for 5 minutes. He was refered to the emergency room of our Hospital “Instituto Nacional de Rehabilitación ‘‘ in Mexico City, Mexico. During his hospitalization he was admitted to ICU and went to the OR for debridement of necrotic tissue. On physical examination he had bone exposure of the temporal, parietal and occipital bone in the right hemicranium, with presence of soft tissue necrosis with a diameter of 20X5 cm and involvement of the aesthetic unit of the ear. The patient had a negative pressure system prior evaluated for reconstruction. Surgical reconstruction was performed using a latissimus dorsi free flap micro anastomosed to the superficial temporal vessels.The patient was seen again 7 days later, he was well with no evidence of flap necrosis. He was followed up for an additional six months with good evolution. Results We present a successful case of a patient who was reconstructed with a Free Lattissimus dorsi flap. Conclusions With its numerous advantages, the function-preserving split latissimus dorsi muscle flap provides an excellent option as a free flap for skull reconstruction. Applicability of Research to Practice The goals of reconstructive surgery for the burn patient are to restore function and aesthetic appearance. The goals of scalp reconstruction are to provide full coverage of the calvarium to prevent desiccation, sequestration, infection, and cover the defect with hair-bearing skin. Vascular damage caused to the vessels by electricity includes blood vessel occlusion and endothelial cell death which continues increasing, from 30 min to days after burn, causing a cessation of blood flow, which makes preferable to look for a receiving vessel that have better condition than the nearest one. Funding for the Study N/A

ABSTRACT Osteoradionecrosis (ORN) of the chest wall is a rare and late complication which occurs in about 1%–7% of individuals undergoing radiation after breast cancer surgery. Management of the condition has to be customized according to the individual patient concerns as there are no established guidelines. Surgical debridement of the nonviable skin, soft tissue, cartilage and bone followed by coverage of the defect with well-vascularized muscle offers pain relief and wound cover. In this report, a case of ORN of the right chest wall which was managed successfully is presented. An elderly female came with complaints of chronic nonhealing wound in the right chest wall for the last 6 months. She had undergone oncological management (Surgery + Chemo and radiation) of the right breast cancer 14 years ago and since then had an uneventful life. She had developed blisters and watery discharge followed by skin breakdown and ulceration for the last 6 months. The diagnosis of ORN was confirmed with a biopsy of the lesion and computed tomography scan of the chest. After cardiac and anesthesia assessments were completed, she was taken for surgery under general anesthesia. Wide excision of the lesion was done followed by coverage of the defect by mobilization of the pectoralis major myocutaneous flap from the left side. Although contralateral and ipsilateral latissimus dorsi muscle use for chest wall reconstruction are reported in the literature, use of contralateral pectoralis major muscle is not yet reported and the authors infer that contralateral pectoralis major muscle and myocutaneous flaps offer an alternate option in addition to latissimus dorsi muscle or myocutaneous flaps in selected cases.

Indocyanine Green Fluorescence Angiography as a Predictor of Distal Flap Necrosis in Latissimus Dorsi Free Flaps.

Reconstruction of Large Post-traumatic Defect over Upper Chest with Open Clavicle Fracture by Latissimus Dorsi Muscle Flap

The author for a case of breast preservation with latissimus dorsi muscle skin flap transplantation and breast reconstruction surgery and nursing, through preoperative visit, personnel, goods, drugs, intraoperative with surgeon, anesthesia, intraoperative acquired stress injury prevention, closely observe vital signs, intraoperative airway management, surgeons, anesthesiologists, instrument nurses, itinerant nurses, high quality surgery, postoperative bedside visit, provide patients with continuous, high quality perioperative care, finally complete the operation safely, no intraoperative complications. Therefore, in breast cancer breast surgery with longus dorus muscle flap transplantation breast reconstruction process, give the continuous, high quality surgical care, can simplify the surgical procedures, reduce the intraoperative position change may reduce incision bleeding, intraoperative acquired stress injury such as surgical adverse reactions, shorten the operation time, improve the patient feeling and experience.

Background: Non-healing soft tissue defects pose challenges to treating physicians. Microsurgical reconstruction is a treatment option for achieving wound closure and limb salvage. These free tissue transfers are often challenging due to associated risk factors. This study aimed to evaluate microsurgical reconstruction using specialized microsurgical techniques for non-healing spontaneous or post-traumatic soft tissue defects in an elderly, high-risk patient cohort with peripheral artery disease. Methods: A retrospective study was conducted on patients with radiologically confirmed peripheral artery disease who underwent free tissue transfers between 2004 and 2010. Patients were included in whom one of two surgical techniques was used, including a "Y" configuration of the arterial pedicle, employed either as an interposition graft or as an arterial patch, or the use of a saphenous vein graft. Patient demographics, comorbidities, flap/limb survival, and surgical techniques were analyzed. Results: Twenty patients at a mean age of 68 (+/-9.3) years underwent 21 primary flap surgeries. Trauma-derived soft tissue defects were predominant (55%). Latissimus dorsi muscle flaps were most frequently utilized (52.4%). The flap success rate was 90.5% at a 12-month follow-up, with no secondary amputations recorded. The lost flaps were replaced by additional free tissue transfers without further complications. Conclusions: This study demonstrates the feasibility of free tissue transfers in high-risk patients with complex soft tissue defects and vascular calcifications. Thorough preoperative planning and the application of specialized surgical techniques are crucial for favorable outcomes in challenging clinical scenarios.

AimsThe free latissimus dorsi muscle (LDM) flap represents a workhorse procedure in the field of trauma and plastic surgery. However, only a small number of studies have examined this large group of patients with regard to the morbidity of flap harvest. The aim of this prospective study was therefore to objectively investigate the morbidity of a free LDM flap.MethodsA control group (n = 100) without surgery was recruited to assess the differences in strength and range of motion (ROM) in the shoulder joint with regard to handedness of patients. Additionally, in 40 patients with free LDM flap surgery, these parameters were assessed in an identical manner.ResultsWe measured higher values for all parameters assessing force in the shoulder joint on the dominant side of patients in the control group. Moreover, LDM flap harvest caused a significant reduction in strength in the glenohumeral joint in all functions of the LDM that were assessed, ranging from 9.0% to 13.8%. Equally, we found a significantly reduced ROM in the shoulder at the side of the flap harvest. For both parameters, this effect was diminished, when the flap harvest took place on the dominant side of the patient.ConclusionLDM flap surgery leads to a significant impairment of the strength and ROM in the shoulder joint. Moreover, the donor morbidity must be differentiated with regard to handedness: harvest on the non-dominant side potentiates the already existing difference in strength and ROM. Conversely, if the harvest takes place on the dominant side of the patient, this difference is diminished.Cite this article: Bone Jt Open 2024;5(12):1114–1119.

Poland syndrome is a rare congenital chest wall developmental defect. Traditional reconstruction applies open to harvest of the latissimus dorsi muscle flap, but issues like large incisions and high complication rates exist. Endoscopic-assisted harvest of the latissimus dorsi muscle flap has minimally invasive advantages worth exploring for application in Poland syndrome patients. We retrospectively analyzed the surgical situations of five Poland syndrome patients at our center, and systematically searched the literature, including 31 cases of endoscopic-assisted latissimus dorsi muscle flap reconstruction. Data on surgical complications, postoperative shoulder function scores, aesthetic scores, and patient satisfaction were collected and comprehensively analyzed in combination with literature reports. Endoscopic surgery had smaller incisions, fewer complications, shorter recovery time, and high patient scar satisfaction. Postoperative aesthetic results were good, but the obtained flap tissue volume was limited. Upper limb function at the donor site was preserved, but there was some degree of strength decline. Endoscopic-assisted latissimus dorsi flap surgery (ELDM) allows for clear visualization of the surgical field, reduces complications, minimizes scarring, shortens recovery time, and provides better cosmetic results, making it suitable for young Poland syndrome patients seeking improved aesthetic outcomes. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The demand for breast reconstruction is increasing constantly, which leads plastic surgeons to look for new methods to obtain a more natural and aesthetically pleasing appearance of the reconstructed breasts. The latissimus dorsi (LD) muscle has been adopted as one of the workhorse flaps for breast reconstruction. Objective: Report a breast immediate reconstruction through a latissimus dorsi muscle flap with breast implants and contralateral simetrization. Clinical Case: 47 years old female with a right ductal invasive breast carcinoma with a partial oncological response after neoadjuvant treatment and Forrest total right mastectomy and immediate reconstruction by the Plastic and Reconstructive service using a hybrid technique. Discusion And Conclusion:Among all the surgical methods, modified mastectomy is adopted most commonly in China; however, it has been found to have negative psychological effects on women’s emotion and affects their quality of life. The latissimus dorsi (LD) flap is a commonly used technique in reconstructive surgery. It is an autologous tissue that can cover a large area, for defects due to trauma, wide excision, or tumors. It is one of the most commonly used flaps in reconstruction of small to moderate breast volumes. The latissimus dorsi muscle flap with breast implants and contralateral simetrization are both an excellent reconstructive alternative to the breast reconstruction after Forrest mastectomy defects in the same surgical time.

Large scalp and calvarial defects pose significant challenges for reconstruction. Successful reconstruction necessitates soft tissue restoration capable of withstanding radiation following tumor resection. Free flaps allow preserving and maintaining the structural and functional status of the reconstructed area. This article presents our experience with microsurgical free tissue transfer for scalp and calvarial defects as well as a literature review on the subject. A retrospective study was conducted to retrieve the files of all the extensive scalp/forehead defects with dural exposure treated in the plastic surgery department of Hotel Dieu de France University Hospital from September 2006 to December 2023. Twelve free tissue transfers were performed in 11 patients between 2006 and 2023. In 3 cases, a 2-stage procedure was performed with the transfer of the free flap in the first stage and the ablative surgery in the second stage 1 week later. A muscular latissimus dorsi flap was used in 9 cases. In 3 patients, the defect involved the forehead and required cutaneous flaps: 2 radial forearm flaps and 1 parascapular flap. Complications included 1 flap venous thrombosis, 2 hematomas, 1 subdural hematoma, and 2 cases of distal flap necrosis. Free tissue transfer is indispensable for addressing large defects of the scalp and calvaria. A 2-stage operation is warranted for debilitated patients with a high risk of complications. The latissimus dorsi muscle flap is the flap of choice to cover extensive defects. Delayed cranioplasty is preferable in contaminated wounds.