Background:  Angiosarcoma is a rare, aggressive malignancy that is most commonly found in the head and neck region. Intraoperative rapid frozen section histology is frequently misleading.  This poses a concern for the surgeon regarding the timing of the reconstruction.  We present a case that illustrates this point and demonstrates effective management of a total scalp defect.

Case Presentation:  The patient is a 72 year old Caucasian gentleman with extensive scalp angiosarcoma.  He underwent three separate excisions by the head and neck oncology service for positive margins on the permanent histology that had initially been reported negative by rapid frozen section.  Each time, we chose to postpone definitive reconstruction until the permanent pathology was evaluated.  This was accomplished by using Integra™ Artificial Skin as a temporary dressing.  The final defect involved the entire scalp.  The final reconstruction was performed using a single thoracodorsal pedicle latissimus dorsi-serratus anterior muscle free flap, followed by split thickness skin grafting.  At the conclusion of the case, a four-poster halo vest was applied by the neurosurgical service to prevent pressure on the posterior aspect of the flap.

Conclusions:  Due to the unreliability of intraoperative rapid frozen section, we recommend that definitive reconstruction of a scalp angiosarcoma be delayed until permanent sections are reviewed.  Furthermore, a combination latissimus dorsi-serratus anterior free flap based on a common pedicle is a streamlined solution to a large scalp defect.  Finally, a neurosurgical halo vest is a useful adjunct to protect a posterior scalp flap from pressure necrosis.