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Yang et al. Plast Aesthet Res 2021;8:54 https://dx.doi.org/10.20517/2347-9264.2021.40 Page 5 of 12

healing wound/exposed hardware (n = 2, 6.2%), see Figure 3.

Defect size and depth
The majority of the large defects (n = 22) were reconstructed via the Integra/ Integra + STSG method
(59.1%). Breakdown of defect size and type of reconstruction can be seen in Figure 4.

Previously radiated patients were either reconstructed with free tissue transfer (n = 4, 12.5%) or Integra (n =
5, 15.6%). Immunosuppressed patients were all reconstructed with Integra (n = 3, 100%).

All exposed dura defects were reconstructed with free tissue transfer (n = 3, 100%). The majority of the
partial bone defects with intact inner calvarium were reconstructed with Integra (n = 12, 63.1%), see
Figure 5.

Complications
Four patients reconstructed with Integra were required to return to the operating room for revision surgery.
Patient 1 had a persistent area of exposed bone and required coverage with more Integra. Patient 2 had a
history of prior kidney transplant with poor wound healing and only had 60% Integra take, requiring
another layer to be placed. Patient 3 developed a hematoma under the Integra, preventing any take of the
graft. Finally, patient 4 had 85% take with a small area of exposed bone that developed while undergoing
radiation treatment.

One patient reconstructed with a local flap required revision surgery due to distal necrosis. Integra was used
for coverage of the defect. Patients reconstructed with local flaps, tissue expanders followed by local flaps, or
free tissue transfer did not have any post-surgical complications.

DISCUSSION
Reconstruction of large and full-thickness scalp defects has been challenging. However, the advent of
microvascular free tissue transfers in 1959 has greatly expanded the options and versatility of
[21]
reconstruction . It provides consistently vascularized tissue and more robust soft tissue volume, especially
important if postoperative radiation is pursued . Thus, it has been established as an efficacious method.
[22]
Traditionally, the latissimus dorsi flap [23,24] has been the most commonly used, but the anterolateral thigh
flap has also emerged in recent years as another frequently used flap [25-27] . The radial forearm flap , rectus
[28]
[30]
abdominus flap , and free omentum covered by a skin graft are other described forms of reconstruction.
[29]
Some proponents for free tissue reconstruction of scalp defects argue that this may be the more conservative
option given that other methods of reconstruction such as local flaps or STSG may result in the need for
[31]
multiple procedures, prolonged wound care, and unsatisfactory aesthetic result . Numerous algorithms
have been previously published in literature with recommendations on how to reconstruct large and/or full-
thickness scalp defects. Prior literature has suggested free tissue transfer [Figure 6] with defects larger than
100 cm and previously irradiated scalps , defects > 100 cm wanting single stage reconstruction , size >
2
[33]
2
[32]
[34]
2
8 cm , and large scalp defects defined as > 90 cm whether they are partial or full-thickness .
[18]
Free tissue transfer is not without its risks of associated surgical complications such as flap failure and
medical complications related to longer operative times and inpatient stays. Older age has been suggested as
a possible risk factor for postoperative complications following microvascular procedures, but numerous
studies have proven that age alone was not an independent risk factor [35-40] . Rather, frailty and patient co-
morbidities may provide a more meaningful evaluation of an elderly patient’s candidacy for surgery and