Local flap guidance for scalp reconstruction following Mohs micrographic surgery

Keratinocyte carcinomas (KCs) are commonly located on the scalp and often treated with excision with peripheral and deep en face margin assessment (PDEMA), with Mohs micrographic surgery (MMS) being the most frequently used method. Resection of these malignancies results in wounds with a wide variety of sizes, ranging from small, sub-centimeter defects, to extensive, nearly complete scalp defects. MMS is often the preferred treatment for tumor resection and margin clearance, as it allows for maximal healthy tissue preservation and has the lowest recurrence rates. Multiple local flap reconstruction options exist, and the selection depends on the size and location of the defect. This review highlights the indications, typical locations, potential risks, and advantages of frequently used local flaps on the scalp, accompanied by artistic representations of each flap herein. An exhaustive list of the local scalp flaps discussed in this review includes single, bilateral, and triple rotation flaps, the pinwheel flap, the double hatchet flap, the triple rhomboid flap, both the unilateral and bilateral banner flaps with split thickness skin grafts, A to T flaps, H-plasty flaps, single and double bridge flaps, and the pacman flap. Inelasticity of the scalp inhibits tissue movement so flaps on the scalp must be designed to be much larger than flaps in most other facial locations. One of the greatest benefits of working with local flaps on the scalp is often the presence of hair-bearing skin which provides the reconstructive surgeon the ability to hide significant scars under hair-bearing scalp, and the ability to perform wound repair under local anesthetic immediately following tumor removal by MMS.