Microsurgical reconstruction of complex scalp defects: An appraisal of flap selection and the timing of complications

Background: The purposes of this study were to report a 7-year experience of microvascular reconstruction of scalp defects, compare flap type and outcomes, and evaluate the implications of short and long term complications. Methods: Following institutional review board approval, a single surgeon's patients requiring microvascular scalp reconstruction were retrospectively reviewed from 2005 to 2011. Flap choice, complications, and outcomes were statistically analyzed. Results: Nineteen patients met inclusion criteria (10 male and 9 female) with a mean age of 60.2±21.4 years (range, 23-90 years). All free tissue transfers (n=20) achieved 100% soft tissue coverage. Mean size calvarial defect was 106.6±67.2 cm2 (range, 35-285 cm2), with 11 requiring cranioplasty. Free flaps included the following: 13 anteriolateral thigh, 5 ulnar, 1 latissimus dorsi, and 1 thoracodorsal artery perforator. Mean flap size was 154.1±87.3 cm₂ (range, 42-336 cm2). Early complications (>30 days following surgery) occurred in 21.1% of patients and late complications (<30 days following surgery) in 52.6% of patients. Patients with an early complication were 2 times more likely to develop a late complication (relative risk, 2.1) but did not reach statistical significance. Late complications were more likely to require surgical intervention, 84.2% versus 60% of early complications (P=0.079). Conclusions: Microvascular free tissue transfer is the mainstay of complex scalp defects but carries a high likelihood of future reoperations. Early complications are less concerning than late complications, as the need for future surgical intervention is associated with late complications. There is lack of evidence to support a superior flap choice.