Microvascular approach to scalp replantation and reconstruction: a thirty-six year experience

Soft tissue defects of the scalp may result from multiple etiologies and can be challenging to reconstruct. We discuss our experience with scalp replantation and secondary microvascular reconstruction over 36 years, including techniques pioneered at our institution with twin-twin scalp allotransplant and innervated partial superior latissimus dorsi (LD) for scalp/frontalis loss.

A retrospective review of all patients presenting with scalp loss requiring microvascular reconstruction at a single center was performed from January 1971 to January 2007. Medical records were reviewed for age, gender, defect size/location, etiology, type of reconstruction, recipient vessels used, vein grafts, and complications.

Thirty-three patients were identified; mean age was 33 years (range, 7-79). Mean scalp defect size was 442 cm(2) (range, 120-900 cm(2)). Thirty-six microvascular reconstructions were performed; of these, 10 scalp replants and 26 microvascular tissue transfers. Of these 26, 17 were LD based (partial superior LD with and without reinnervation, LD combined with serratus, LD combined with parascapular, LD combined with split rib, LD only) and 2 free scalp allotransplant among others. The superficial temporal artery and vein was used as recipient vessels in 70% of cases. Overall, microvascular success rate was 92%; complications occurred in 14 cases, nine major (tumor recurrence [n = 2], partial flap loss [n = 2], replant loss [n = 3, size <300 cm(2) ], hematoma [n = 2]) and five minor (donor site seroma /hematoma [n = 3], flap congestion [n = 1], superficial wound infection [n = 1]).

Every attempt should be made at scalp replantation when the patient is stable and the parts salvageable. Larger avulsion defects had higher success rates after replantation than smaller defects (<300 cm(2) ), with the superficial temporal artery and vein most commonly used for recipient vessels (P = 0.0083). Microvascular tissue transfer remains a mainstay of treatment for scalp defects, with LD-based flaps, demonstrating excellent versatility for a range of defects.