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Byline: Aamna Sanober, Mamoon Rashid, Shumaila Yousaf, Ishtiaq-Ur-Rehman, Samia Fatima and Farhan Ahmed Eitezaz


Objective: To determine the outcomes of free tissue transfer for large scalp and forehead defects reconstruction.

Study Design: A descriptive case series.

Place and Duration of Study: The study was carried out at Plastic surgery department, Shifa International Hospital Islamabad, over a period of 5 years from Mar 2011 to Feb 2016.

Material and Methods: All the patients who underwent scalp reconstruction for soft tissue or composite defects greater than 6cm2 during the period of 5 years were included in the series and were followed post operatively for 6 months. The patient's demographic data, medical history, surgical history, comorbidities, age, and gender were also analyzed. Indications for surgical intervention included cutaneous malignancy of the scalp, bony tumors, vascular lesions and traumatic tissue loss requiring reconstruction.

Results: A total of 20 patients (60% female and 40% male) with mean age of 38.75 years (SD=14.44), who under-went a reconstructive surgery for scalp defect, were assessed. The scalp defect were secondary to tumor resection (n=10; 50%), post-traumatic wounds (n=5, 25%) and resection of vascular malformations (n=5, 25%). Free flaps used for reconstruction were: Antero Lateral Thigh Free Flap (ALTF) (n=8; 40%), Radial Forearm Free Flap (RFFF) (n=6, 30%), free latissimus dorsi (n=4, 20%) and Transversus Abdominis muscle (TRAM) flap (n=2, 10%).

Conclusion: Scalp and forehead defects, if treated adequately, can heal with stable and aesthetically acceptable results and flap selection should be individualized according to the defects, patient's factors and availability of particular flap.

Keywords: Forehead defect, Free flap, Scalp defects.


The treatment of scalp and forehead defects can be extremely challenging. Scalp defects are classified according to the size of defect (table-I) their etiology and the involvement of soft tissue only/bony component. Defects of the scalp arise from several diverse etiologies including trauma, burn injury, infection, radiation, surgical excision of tumor, or congenital lesion1. The goal of reconstruction for scalp and forehead defects is to achieve a stable coverage with acceptable aesthetic results. Smaller defects can be closed primarily where as reconstructing a large scalp defect poses a challenge in terms of availability of loco-regional tissue and probable need for bony reconstruction along with it. Advances in micro-surgical techniques allowed free flaps to emerge as an additional and possibly superior option for scalp reconstruction2.

Rotation flaps are a convenient method of reconstructing small to moderate sized scalp defect but when dealing with large to very large defects, scalp rotation remain inadequate for complete coverage. In spite of this, scalp rotation flaps are frequently utilized for restoration of hairline wherever possible in adjunct with other soft tissue coverage.

Various local flaps3,4 distant pedicled flaps5,6 and free flaps7,8 have been suggested for scalp reconstructions. Free flap reconstruction has rapidly established itself as a desirable and versatile option for repair of defects of the scalp, especially in more complex cases9,10. Trapezius and latisimus dorsi pedicled flaps are good alternative for posterior scalp defects, but defects at the vertex and anterior to it, involving forehead needs coverage that is not only stable but also should be aesthetically acceptable. Free radial forearm fasciocutaneous flap, Anterolateral thigh free flap and other fasciocutaneous free flaps give good color match and ease of free designing as well as lesser risk of partial necrosis.

Table-I: Classification of Scalp Defects.

S. No###Defect###Size (cm2)###Options

###1###Small###9###Free tissue transfer/Skin Graft

Table-II: Type of reconstruction and associated complications.

Free###Skin graft loss###Wound###Re-



ALTF###8 (40%)###01 (12.5%)###-###-###01 (12.5%)###02 (25%)###None

RFFF###6 (30%)###None###-###-###01 (16.6%)###None###None


###4 (30%)###None###-###02 (50%)###None###02 (50%)###None


TRAM###2 (10%)###None###-###-###None###None###None

Total###20###01 (5%)###02 (10%)###02 (10%)###04 (20%)###O

Table-III: DONOR site complications.

Flap###ALTFF###RFFF###Lat Dorsi###TRAM

###Parietal: 3 (37.5%)###Frontal: 3 (15%)

Location of###Parieto-occipital:###Orbital and

###Fronto-temporal: 2 (25%)###Fronto-parietal:

defect###4 (20%)###frontal: 2 (10%)

###Temporal: 3 (37.5%)###3 (15%)

Donor site###Donor site partial graft###Donor site partial###Donor site seroma:


Complication###loss: 3 (37.5%)###graft loss: 1 (16.7%)###2 (50%)

Scalp defect are being managed at various reconstructive centers in the country but till date no authentic data is available regarding the outcome where free flaps are used. The aim of this study is to present our experiences of recon-structing large scalp defects using microvascular free tissue and to compare various free flaps for their effectiveness in achieving aesthetically better outcomes.


After approval of the ethical review committee, a descriptive prospective case series study was conducted at Shifa International hospital. It included all patients who underwent scalp reconstruction for soft tissue or composite defects greater than 6cm2 using free tissue transfer; over a period of 5 years from 1st March 2011 to 29th February, 2016. Inclusion criteria was large scalp and forehead soft tissue only or composite defects including post tumor extirpation defects following tumor margin clearance, defects after resection of congenital malformations in patients aged between 10-70 years of both genders.

Patients with contaminated or dirty wounds, defects less than 6cm2, age 70 years were all excluded as possible confounders.

Also the patients, in whom skin graft or only loco-regional flaps were used for coverage, were excluded. Independent variables included primary diagnosis, defect size, method of recon-struction and complications. The patient's demographic data, medical history, surgical history, additional co-morbidities, age and gender were also analyzed. Indications for surgical intervention included cutaneous malignancy of the scalp, bony tumors and vascular lesions.

In cases of anticipated skull bone involvement, neurosurgical team was taken on board.

Bone grafts either from rib or split skull bone was incorporated for bony reconstruction. In cases of tumor, preoperative workup included incisional biopsy for histopathologic diagnosis and excision was done under frozen control to confirm margin clearance.

In cases of trauma, initially, effective debridement was done followed by negative pressure wound therapy or early coverage of wounds if there was exposure of vital structures. Decision was taken by the operating surgeon for the selection of flaps according to the defect size and location. Donor site morbidity was assessed on follow up visits. Minimum follow up of patients was 6 months.

All the patients were observed for any wound infection, seroma, hematoma, graft loss and any donor site complications. The data was analyzed using SPSS software, standard deviation and frequencies of complications were noted.


A total of 20 patients (60% female and 40% male) with mean age of 38.75 years (SD=14.44) who underwent reconstructive procedures were included in the study. The defects included were secondary to tumor resection (n=10, 50%), posttraumatic wounds (n=5, 25%) and resection of vascular malformations (n=5, 25%). Free flaps used for reconstruction were: Antero lateral thigh free flap (ALTF) (n=8, 40%), Radial forearm free flap (RFFF) (n=6, 30%), free latissimus dorsi (n=4, 20%), Transversus Abdominis muscle (TRAM) flap (n=2, 10%). Lat. dorsi with skin graft was used for very large defects involving parieto-occipital region. Antero lateral thigh free flap (ALTF) was mostly used for defects of parietal region and some in temporal region as well. Radial forearm free flap (RFFF) was utilized in patients with forehead and frontal defects (fig-1,2).

The table-II shows the main complications that were assessed in our study associated with different reconstructive methods.

The main complication seen was wound dehiscence (20%) in Antero lateral thigh free flap (ALTF) (25% cases) and Lat. dorsi flaps (50% cases), although it did not need resuturing but prolonged patient hospital visits for wound care. Another complication seen was skin graft partial loss, more common with latissimus dorsi flaps (10%) which did not require any intervention. None of the patients required re exploration.

The table-III shows the donor site compli-cations observed in the study. The complication associated with latissimus dorsi flap was donor site seroma (n=2, 50%), which was drained and resolved without sequalae. There was partial graft loss on Radial forearm free flap (RFFF) donor site (n=1, 16.7%) and Antero lateral thigh free flap (ALTF) (n=3, 37.5%) that eventually healed secondarily. There was no functional deficit in limbs in cases of Radial forearm free flap (RFFF) or Antero lateral thigh free flap (ALTF).


Reconstruction of scalp is different from other body parts; many important factors are to be considered when planning reconstruction of scalp and forehead, the main consideration being the anatomic nature of the scalp having limited elasticity, which renders primary closure of wounds more than 50 cm2 extremely challenging1,3. In most of the studies conducted, the primary closure was only feasible where the defect was smaller than 6 cm2. Complex and large defects can be reconstructed by using either free flaps or local or distant pedicled flaps depending on the size, location, and etiology of the defect2. Critical and thorough analysis of the respective defect is highly recommended4.

Local flaps usage has the benefit of hair bearing skin coverage giving an acceptable and more cosmetic result without the use of any regional or distant body areas reducing the morbidity in comparison but their implication is more limited in cases of larger defects. A lot of undermining is usually necessary to elevate an adequate flap size pliable enough to cover the defect and skin graft over the donor area5.

Using skin grafts gives an advantage of covering an area as large as 100cm2 with partial thickness grafts in a simplest way but associated with an inferior cosmetic outcome especially when meshed. Being less durable, they are more prone to recurrent ulcer formation, the risk of partial or complete loss with bony exposure, especially in post-radiotherapy cases6.

Using distant pedicled flaps such as trapezius, pectoralis or latissimus dorsi flaps has an advantage of effective and durable coverage with relatively easier procedure. But the drawback of donor site morbidities and the higher possibility of flap loss, especially with senility or associated co-morbidities as diabetes or cardiac conditions make them the less likely options to be considered. Moreover the flap is bulky and non hairy4.

Decision for using a free flap is dependent on various factors including location and size of the defect, previous reconstructive attempts, patient's age and body habitus, consideration of donor-site morbidity, depth of the defect and preference of the operating surgeon2,6.

Free flaps are considered where the primary site blood supply is poor, rotational flaps not possible or already consumed3,5. Our study showed that free tissue is a versatile option for adequate coverage of large scalp defects and give ease of free designing for the given size and site.

Literature showed that most of the large scalp defects were reconstructed using a latissimus dorsi free flap (49%, n=280/567), rectus abdominis (17%, n=96/567) and anterior lateral thigh flap (14%, n=77/567). Radial forearm free flap was surprisingly rarely used (8%, 44/567)4.

In our study, Antero lateral thigh free flap (ALTF) was a considerably convenient and a versatile option as it gives a large surface area and long pedicle length as well as the feasibility of harvesting a chimeric flap including part of the muscle if required to fill the dural defect but color match was not good compared to the forehead skin. Its dissection is also demanding and vascular anatomy is variable. It has more bulk in cases of females than males as also identified by Larranaga et al. It accompanies the benefit of hidden donor site and no functional deficit of the limb used as well as simultaneous harvest in two-team approach2.

Radial forearm free flap (RFFF) give excellent color mach and advantage of reliable and longer pedicle, easy harvest and shorter operative time. The main disadvantages are the prominent scarring over the exposed area and size limitation7.

Latissimus dorsi is a valid option when a very large surface area is involved especially at the parieto-occipital region. It gives good thin pliable coverage especially over the infected areas. The shortcoming of this flap is a small size skin paddle with myocutaneous flap due to difficult donor site closure and wound dehiscence with larger skin paddles or a skin grafted donor site. Donor site seroma is a common complication due to large cavity after flap harvest but is mostly temporary10.

Our study showed that because of the aesthetic burden associated with free flaps, they are very demanding technically and take more operative time yet they provide the best cosmetic and functional results9.

Although the outcomes observed with radial forearm free flap were significantly better and aesthetically pleasing especially in frontal defects, size limitation and exposed donor site renders the decision of using this flap difficult in most of the patients. In cases of very large defects, lat. Dorsi muscle with skin graft is the flap of choice. The Antero lateral thigh free flap (ALTF) is especially useful owing to its versatility, as well as the option of simultaneous harvest, and its minimal donor site morbidity.

Scalp and forehead defects, if treated adequately, can heal with stable and aestheti-cally acceptable results. Choice of method of reconstruction must follow the reconstructive ladder putting in mind certain factors as the defect size, skin pliability, local tissue vascularity, and patient general condition. In all cases in which direct closure is not possible, the local, pedicled, and free flaps discussed provide a good option for coverage. Attention to the vascularity of the scalp is crucial in planning local scalp flaps. Proper design of local scalp flaps includes incorporation of major vascular pedicles within broadly based flaps and closure without excessive tension.


We concluded that flap selection is individualized according to the defects, patient's factors and availability of particular flap.


This study has no conflict of interest to declare by any author.


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3. Eck DL, Koonce SL, Al Majed BM, Perdikis G. Evaluation of Options for Large Scalp Defect Reconstruction: A 12-Year Experience. Eplasty 2014; 14: e10.

4. Larissa Sweeny, Brendan Eby, J Scott Magnuson, William R Carroll, Eben L Rosenthal. Reconstruction of scalp defects with the radial forearm free flap. Head and Neck Oncology 2012, 4: 21.

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8. Singh M1, Rios Diaz AJ, Cauley RUse of Pedicled Trapezius Myocutaneous Flap for Posterior Skull Reconstruction. J Craniofac Surg 2015; 26(6): e532-5.

9. Khan MN, Rodriguez LG, Pool CD, Laitman B, Hernandez C, Erovic BM, et al. The versatility of the serratus anterior free flap in head and neck reconstruction. The Laryngoscope.

10. Kim JT, Kim SW, Youn S, Kim YH. "What is the ideal free flap for soft tissue reconstruction? A ten-year experience of microsurgical reconstruction using 334 latissimus dorsi flaps from a universal donor site." Annals of plastic surgery 2015; 75(1): 49-54.
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Publication:Pakistan Armed Forces Medical Journal
Date:Apr 30, 2018

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