Double Rotational Flaps for Scalp Reconstruction: A Three-Case Series

Scalp reconstruction after oncologic resection remains challenging because of limited scalp elasticity and the need for adequate vascular perfusion. Aging and androgenetic alopecia are associated with well-described biological and structural changes in the scalp; however, whether these changes have clinically meaningful effects on local flap perfusion, viability, or postoperative healing remains uncertain. This series of three cases describes patients undergoing scalp tumor excision followed by reconstruction using double rotational flaps in similar anatomical regions. Case 1 involved a 56-year-old man with a hair-bearing scalp and nodular basal cell carcinoma. The surgical specimen had a documented scalp thickness of 0.9 cm. Postoperative healing occurred without complications. Case 2 involved an 88-year-old bald man with advanced androgenetic alopecia and invasive squamous cell carcinoma. The surgical specimen measured 2.9×2.8 cm and had a documented scalp thickness of 0.4 cm. Closure was achieved under clinically assessed moderate tension. The patient developed an approximately 1×5 cm area of superficial distal flap necrosis, which was managed conservatively with collagenase ointment and local wound care, with secondary healing by postoperative day 54 without reoperation. Case 3 involved a 73-year-old woman with a hair-bearing scalp and invasive moderately differentiated squamous cell carcinoma. The surgical specimen measured 2.9×2.5×0.5 cm, with tumor invasion extending to the deep dermis and evidence of perineural invasion. The documented scalp thickness was 0.5 cm. Postoperative healing occurred without flap necrosis or wound dehiscence. These observations raise the hypothesis that factors beyond measured scalp thickness may warrant further investigation in scalp reconstruction. However, the different postoperative outcomes cannot be attributed to androgenetic alopecia or scalp tissue characteristics because vascular perfusion and tissue quality were not objectively measured, and patient- and procedure-related factors, including closure tension, may have contributed. Prospective studies incorporating objective assessments of scalp tissue characteristics, perfusion, biomechanics, and relevant clinical and technical variables are needed to evaluate this hypothesis.