Complex Scalp and Skull Reconstruction: A Reconstructive Algorithm

INTRODUCTION: We present a case series and a reconstructive algorithm for complex scalp and skull reconstruction.

 MATHERIALS: We retrospectively evaluated patients operated between 2010 and 2017 for large defects of the scalp or combined skull defects (skin + bone ± dura mater). Data on defect etiology, size and location, type of reconstruction, early and long term complications and functional and aesthetic outcomes were extrapolated. A reconstructive algorithm was elaborated based on study results.

 RESULTS: Most of the 24 cases were oncological (59%). A bone defect was present in 68% and a dura mater defect in 14% of cases. All patients underwent microsurgical reconstruction. Muscle free flaps were used in all but one case. Vascular grafts were rarely needed (1/24). Complications included 1 flap failure and 2 post-operative infections (conservately solved).

Muscle-sparing harvesting technique and post-operative muscle atrophy allowed for a good aesthetic result and adequate flap thickness, also for the frontal region. The average follow-up was 27 months.

The following reconstructive algorithm is suggested:

-    SKIN: Muscle-sparing vastus lateralis flap as first choice

• BONE:
  • No bone reconstruction for defect with larger diameter < 3-4 cm
  • no reconstruction/autologous bone graft for defect with larger diameter 4-10 cm for forehead/occipital region.
  • synthetic implant for larger diameter > 10 cm;
  • If infection, bone reconstruction delayed 3-6 months;
• DURA MATER:
  • suture approximation if possible
  • syntetic patch or fibrin glue (non irradiated patients)
  • vascularized fascia (irradiated patients)

CONCLUSION: Complex scalp and skull defect generally require microsurgical reconstruction. Muscle flaps guarantee a reliable coverage for primary or delayed bone reconstruction, and a good aesthetic outcome. The vastus lateralis flap is often indicated due to its large size, long pedicle and functional and aesthetic outcomes. Bone reconstruction is indicated in selected cases, as muscle flaps allow valid protection of deep structure.