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Brawley et al. Plast Aesthet Res 2022;9:6 https://dx.doi.org/10.20517/2347-9264.2021.107 Page 11 of 14

Figure 13. Temporal scalp defect closed with a skin graft from another surgeon, resulting in an unacceptable cosmetic outcome. A
tissue expander was placed posteriorly in the parieto-occipital scalp. Starting on post-operative day ten, 20 mL injections of saline were
initiated, with six additional 20 mL injections at 5-day intervals. After one month, the tissue expander was removed, the skin graft was
excised, and the defect was closed with excellent cosmesis.

[57]
The complications of tissue expansion are well described in the literature . Complication rates are 15%-
[54]
20%, with failures estimated around 6% .
FREE FLAPS
For large and complex defects, free tissue transfer with microvascular anastomosis may be necessary for
optimized closure. Cumulative factors favoring this option include large defects, irradiation, scalp
inelasticity, unfavorable location, chronic wound infection, cranial defect, prior cranioplasty, and/or
exposed implanted structures .
[58]

Flap selection should be dependent on the size of the defect, composite material, aesthetic contour, and
surgeon’s comfort. According to a 2015 pooled analysis of the literature, the most commonly used free flap
on the scalp is the latissimus dorsi flap, with the anterolateral thigh flaps as the second most common .
[59]
Another study noted that the anterolateral thigh flap has been the most commonly reported scalp flap since
2000, inferring increasing popularity . Although advanced age has not been shown to increase mortality or
[60]
complications, patient condition and goals regarding other comorbidities should be discussed and
considered [59,61] .

CONCLUSION
Scalp reconstruction should be approached via the reconstructive ladder, with special consideration to
safety, success probability, and aesthetic optimization. Choosing the best method of reconstruction is
dependent on scalp complexities, defect size, location, tissue viability, hairline distortion, and surgeon
expertise. The key cosmetic tenet of replacing “like with like” makes local flaps a preferred option when
plausible.

DECLARATIONS
Authors’ contributions
Made substantial contributions to conception and design of the study and performed literature review and