MICROVASCULAR APPROACH TO SCALP REPLANTATION ANDRECONSTRUCTION: A THIRTY-SIX YEAR EXPERIENCE

FERNANDO HERRERA, M.D.,1,2 RUDOLF BUNTIC, M.D.,1 DARRELL BROOKS, M.D.,1

GREGORY BUNCKE, M.D.,1 and ANUJA K. ANTONY, M.D., M.P.H.1,3*

Background: Soft tissue defects of the scalp may result from multiple etiologies and can be challenging to reconstruct. We discuss our ex-perience with scalp replantation and secondary microvascular reconstruction over 36 years, including techniques pioneered at our institu-tion with twin–twin scalp allotransplant and innervated partial superior latissimus dorsi (LD) for scalp/frontalis loss. Methods: A retrospec-tive review of all patients presenting with scalp loss requiring microvascular reconstruction at a single center was performed from January1971 to January 2007. Medical records were reviewed for age, gender, defect size/location, etiology, type of reconstruction, recipient ves-sels used, vein grafts, and complications. Results: Thirty-three patients were identified; mean age was 33 years (range, 7–79). Mean scalpdefect size was 442 cm2 (range, 120–900 cm2). Thirty-six microvascular reconstructions were performed; of these, 10 scalp replants and26 microvascular tissue transfers. Of these 26, 17 were LD based (partial superior LD with and without reinnervation, LD combined withserratus, LD combined with parascapular, LD combined with split rib, LD only) and 2 free scalp allotransplant among others. The superfi-cial temporal artery and vein was used as recipient vessels in 70% of cases. Overall, microvascular success rate was 92%; complicationsoccurred in 14 cases, nine major (tumor recurrence [n 5 2], partial flap loss [n 5 2], replant loss [n 5 3, size <300 cm2], hematoma [n 52]) and five minor (donor site seroma /hematoma [n 5 3], flap congestion [n 5 1], superficial wound infection [n 5 1]). Conclusions: Everyattempt should be made at scalp replantation when the patient is stable and the parts salvageable. Larger avulsion defects had higher suc-cess rates after replantation than smaller defects (<300 cm2), with the superficial temporal artery and vein most commonly used for recipi-ent vessels (P 5 0.0083). Microvascular tissue transfer remains a mainstay of treatment for scalp defects, with LD-based flaps, demon-strating excellent versatility for a range of defects. VVC 2012 Wiley Periodicals, Inc. Microsurgery 00:000–000, 2012.

Soft tissue defects of the scalp can arise from acute

trauma, extirpation of tumors, radiation necrosis, and

other iatrogenic causes. Reconstructing these defects can

be challenging to the plastic surgeon depending on the

underlying etiology. In the setting of trauma, shearing

forces applied to the scalp may result in avulsion at the

loose areolar tissue layer between the galea and the peri-

osteum. The exact defect size will vary, depending on

specific direction and strength of the force applied. To

obtain good functional and cosmetic results, immediate

revascularization using microsurgical techniques and

replacement of the scalp in the correct anatomical

position is the procedure of choice whenever possible.

Secondary reconstruction is required when the avulsed

portion of the scalp is unsalvageable or fails replantation.

Alternatively, chronic wounds and extirpation of tumors

of the scalp will also require secondary reconstruction.

Microvascular transfers are often adopted in lieu of local

flaps and tissue expansion when the defects are large and

stable soft tissue coverage is not available. Prior to the

advent of microsurgical techniques, replacement of the

avulsed scalp as a composite graft was largely unsuccess-

ful.1 Miller et al.2 were the first to report successful

microvascular replantation of the entire scalp. Since then,

advances in techniques and widespread use of microsur-

gery over the last several decades have made revasculari-

zation and secondary reconstruction of such defects not

only possible but aesthetically pleasing.3–5 We discuss

our experience with scalp replantation and secondary

microvascular reconstruction over 36 years at a single

institution.

PATIENTS AND METHODS

A retrospective chart review was performed for all

patients presenting with scalp loss that required microvas-

cular techniques to reconstruct the defect by either

replantation of native scalp or with the use of free tissue

transplantation from January 1971 to January 2007 at a

single institution (The Buncke Clinic, Division of Micro-

surgical Transplantation and Replantation, San Francisco,

CA). Table 1 summarizes the patient’s demographic data.

The medical records were reviewed for age, gender,

defect size/location, etiology, type of reconstruction, flap

choice, recipient vessels used, vein grafts, complications,

and follow-up. Complications were recorded and divided

into two categories: major and minor. Major flap-related

complications included early return to the operating room

for exploration or hematoma evacuation, partial or

complete flap loss, and tumor recurrence. Minor compli-

cations included superficial wound infections, donor site

hematoma or seroma, and mild flap congestion treated

1The Buncke Clinic and Division of Microsurgery, California Pacific MedicalCenter, San Francisco, CA2University of California Los Angeles, Division of Plastic and ReconstructiveSurgery, Los Angeles, CA3Division of Plastic and Reconstructive Surgery, University of Illinois at Chi-cago, Chicago, IL

*Correspondence to: Anuja K Antony, M.D., M.P.H., Director of Microsur-gery, Division of Plastic and Reconstructive Surgery, University of Illinois atChicago Medical Center, Chicago, Illinois. E-mail: akantony@uic.edu

Received 20 January 2012; Accepted 6 July 2012

Published online in Wiley Online Library (wileyonlinelibrary.com). DOI 10.1002/micr.22037

VVC 2012 Wiley Periodicals, Inc.

conservatively. Fisher’s exact test was performed to ana-

lyze flap failure based on flap size.

RESULTS

Between January 1971 and January 2007, 33 patients

were identified with scalp defects requiring microvascular

reconstruction to replant or cover these acquired defects.

A total of 36 microvascular tissue transfers or replanta-

tions were performed in 33 patients (Fig. 1). Overall, mi-

crovascular success rate in our series was 92%. There

were 17 male and 16 female patients. The average age

was 33 years, ranging from 7 to 79 years and the average

defect size was 442 cm2 (range, 120–900 cm2). The

mean follow-up in our study was 32 months, ranging

from 8 months to 6 years. The soft tissue defects resulted

from a variety of etiologies. Eighteen of these patients

sustained traumatic avulsion of a portion or total scalp;

eight of which were not amenable to replantation. The

majority of the patients in the traumatic group were

female (12) versus male (6). The avulsion injuries were

secondary to motor vehicle accidents in 14 patients, one

go-kart accident, one linen press accident, one drive shaft

accident, and one mountain lion attack. Tumor extirpation

resulted in eight scalp defects; three defects from unsta-

ble scars/chronic wounds; two resulting from radiation

necrosis while treating a scalp malignancy; one wound

was the result of electrical burn; and one wound was

from a birth-related injury.

Ten scalp replants were performed; three failed and

required further reconstruction. One failed replant resulted

from a large scalp hematoma, resulting in extrinsic com-

pression of the pedicle. The other two failures resulted

from venous thrombosis in the early postoperative period.

All three cases resulted in a secondary surgery for explo-

ration and attempts at salvage. Partial avulsion replants of

Table 1. Patient Demographics and Summary

Patient Sex Age Etiology Reconstruction Recipient vessels Vein graft Complications

1 M 26 Avulsion Replanted scalp STAx2, PA Yes None

2 F 17 Avulsion Replanted scalp STA,SOA/STV Yes SSI

3 F 10 Avulsion Replanted scalp STA/FV No None

4 F 27 Avulsion Replanted scalp X No None

5 F X Avulsion Replanted scalp STA/STV Yes None

6 F 33 Avulsion Replanted scalp STA/STV Yes None

7* F 21 Avulsion Replanted scalp STA/STV x Failed replant

8* M X Avulsion Replanted scalp Occipital A/V Yes Failed replant

9* F X Avulsion Replanted scalp STA/STV Yes Failed replant

10 F 22 Avulsion LD/Serratus ant FA/FV No None

11 F 17 Avulsion Latissimus STA/STV No None

12 M 39 Avulsion LD/parascapular X No None

13 M 17 Avulsion Radial FFF X Yes None

14 M 43 Avulsion Partial superior latissimus STA/STV, TdN Yes None

15 M 70 Avulsion Partial superior latissimus STA/FV No Donor site hematoma

16 F 24 Avulsion Latissimus FA/FV No None

17 F 22 Avulsion LD/serratus ant FA/FV No None

18a** F 23 Avulsion Replanted partial scalp LSTA/STV Yes None

b 24 Partial free scalp R STA/STV Yes Hematoma

c 29 Partial free scalp L STA/STV Yes Flap congestion

19 M 29 Neurofibroma Omentum STA/STV No None

20 M 15 Electrical Groin flap STA/STV No Hematoma

21 M 59 Basal cell Groin flap STA/STV No Tumor recurrence

22a** M 7 Congenital Groin flap Occipital A/V Yes Partial flap loss

b Latissimus Sup thyroid a. Yes None

23 M 60 Meningioma Latissimus Occipital A/V Yes Donor site seroma

24 F 17 Medulloblastoma Latissumus STA/STV No None

25 M 32 Fibrosarcoma LD/split rib graft STA/STV No None

26 M 35 Chronic wound Latissimus STA/STV No Partial flap loss

27 F 45 Dermatofibrosarcoma Serratus ant FA/FV No None

28 M 57 Chronic wound Latissimus STA/STV No Donor site seroma

29 M 10 Neurofibrosarcoma Latissimus STA/STV No None

30 M 33 XRT necrosis Serratus ant STA/STV No None

31 F 58 Meningioma Latissimus STA/STV No None

32 F 45 XRT necrosis Latissimus STA/STV No None

33 M 79 Chronic wound Latissimus STA/STV Yes Marjolin ulcer

*Patients 7,8,9 had flap dimensions <300 cm2.**Patient 18 had three microvascular procedures, one partial replantation, and two partial scalp allotransplantation flaps from her twin sister and is designatedas 18 a, b, and c. Patient 22 had two flaps and is designated as 22a and b.

2 Herrera et al.

Microsurgery DOI 10.1002/micr

<300 cm2 were designated as small and those >301 cm2

were designated as large. Smaller replant size <300 cm

was significantly associated with failure (P 5 0.0083).

Secondary microvascular scalp reconstruction was per-

formed in the remaining 23 patients; all secondary flaps

completely survived except for two cases which sustained

partial flap loss. A total of 26 microvascular free tissue

transfers were performed in the secondary reconstruction

group. Flap choices included 17 latissimus dorsi (LD)-

based flaps (two partial superior LD flaps with and without

reinnervation, two LD combined with serratus flap, one LD

combined with parascapular flap, one LD combined with

split rib, and 11 LD only flaps with STSG), three groin

flaps, two serratus anterior flaps, two partial scalp allotrans-

plants from an identical twin, one omental flap, and one

radial forearm fasciocutaneous free flap.

A variety of recipient vessels were used including the

superficial temporal (ST) artery (n 5 26), facial artery

(n 5 4), occipital artery (n 5 3), superior thyroid artery

(n 5 1), supra-orbital artery (n 5 1), and postauricular

artery (n 5 1). The majority of recipient veins used were

the ST veins (>70%), followed by facial vein, and occi-

pital vein in three patients. Vein grafts were required in

15 cases (seven in primary replant and eight in secondary

reconstructive). Overall complications occurred in 14

cases (39%); these were divided into nine major and five

minor complications (Fig. 2). There was no significant

difference in complications between the cases with the

use of vein graft compared to those without (P 5 0.286)

(Table 2). During the third twin–twin transplant operation

(of three surgeries performed in one set of twins), superfi-

cial subcutaneous veins were used for outflow. Postopera-

tively, the flap became very congested requiring leech

therapy. The twins were HLA identical and crossmatched

against each other with no reaction and for that reason

antirejection medications were not used. A representative

case is shown in Figures 3–6.

DISCUSSION

Scalp defects may result from a number of causes

including traumatic, oncologic resection, iatrogenic, radia-

tion induced, and congenital. Replacement of absent tis-

sue can be challenging to the reconstructive surgeon

especially in the face of previous operations, radiation, or

a severely scarred wound bed.6,7 The treatment is based

on the underlying cause, size of the defect, status of the

avulsed parts, and available recipient vessels. Tradition-

ally, scalp reconstruction options range from primary

repair with galeal scoring for small defects (<300 cm2),

local advancement, or rotational flaps for moderate size

defects (2–25 cm2), skin grafting if pericranium is pres-

ent, staged tissue expansion, rotational Orticochea-type

flaps for large defects, and finally microvascular tissue

transfer for very large defects that cannot be managed

Figure 1. Reconstructive flap choices. Scalp replant n 5 10, latissi-

mus only þSTSG (LD only) n 5 11, groin flap (GF) n 5 3, radial

forearm fasciocutaneous free flap (RFFC) n 5 1, omentum n 5 1,

partial superior latissimus (PS-LD) n 5 2, partial free scalp allotrans-

plantation (Scalp Allo) n 5 2, serratus anterior (SA) n 5 2, Latissi-

musþserratus (LD-SA) n 5 2, Latissimus-parascapular (LD-Para) n

5 1, Latissimus-split rib (LD-rib) n 5 1. [Color figure can be viewed

in the online issue, which is available at wileyonlinelibrary.com.]

Figure 2. Microvascular anastomoses. Superficial temporal artery

(STA), facial artery (FA), postauricular artery (PA), occipital artery

(OA), supraorbital artery (SOA), and superior thyroid artery (sup

thyroid). [Color figure can be viewed in the online issue, which is

available at wileyonlinelibrary.com.]

Table 2. Major and Minor Complications

Complication N %

Major 9 25

Tumor recurrence 2 5.6

Partial flap loss 2 5.6

Failed replanted scalp 3 8.3

Flap hematoma 2 5.6

Minor 5 13.8

Superficial wound infection 1 2.7

Donor site hematoma 1 2.7

Donor site seroma 2 5.6

Flap congestion 1 2.7

Total 14 38.8

Microvascular Approach 3

Microsurgery DOI 10.1002/micr

Figure 3. (a, b, c) Twenty-seven-year-old female with total scalp avulsion secondary to a motor vehicle rollover accident. [Color figure can

be viewed in the online issue, which is available at wileyonlinelibrary.com.]

Figure 4. (a, b) Intraoperative preparation of total avulsed scalp part using a stack of towels for positioning. [Color figure can be viewed in

the online issue, which is available at wileyonlinelibrary. com.]

4 Herrera et al.

Microsurgery DOI 10.1002/micr

with alternative techniques.8,9 Microvascular techniques

offer solutions for managing the challenging scalp region

where often local or regional options are limited or

unavailable. Immediate microvascular replantation of par-

tial or complete scalp avulsions injuries should be

attempted in all cases if the patient is stable and the part

is salvageable. Replacing ‘‘like-with-like’’ tissue will

result in the most favorable outcome. Secondary micro-

vascular reconstruction should be reserved for situations

where the avulsed scalp is not salvageable, failed scalp

replantation, and acquired defects.

In our series, the etiology of scalp defects was di-

vided into either acute traumatic or secondary acquired

scalp wounds owing to various causes. In the traumatic

group, over half of the patients underwent scalp replanta-

tion. The remaining eight patients were not candidates for

replantation either secondary to nonsalvageable parts or

delayed presentation. Vein grafts were necessary in two-

thirds of the scalp replantations to avoid microvascular

anastomosis within the zone of injury. We performed both

single arterial and multiple arterial anastomoses in our

replantation group. The ST vessels were used as the pri-

mary recipient vessels in all but one case. The single case

in which the ST vessels were not used was owing to the

posterior location of the defect and the occipital vessels

were used in this patient. The consistent anatomy of the ST

artery makes this a reliable recipient vessel for use in mi-

crovascular surgery.10–12 In the three failed replants, the

partial scalp defect was <300 cm2 and a single arterial and

venous anastomosis were performed. The recipient vessels

used in the failed replants included occipital vessels (n 5

1) and ST vessels (n 5 2), and vein grafting was used in

two cases. Limitations in vessel availability incurring

inflow/outflow obstruction and restricted dimensions (of

the avulsed portion) for adequate debridement of trauma-

tized tissue likely played a role in ultimate failure of the

less sizeable partial scalp replantations.

Very few large series of scalp replantation exist in

the literature since the first successful attempt performed

in 1976.2 Cheng et al. described their series of 20

patients all with avulsion injuries of the scalp. They

reported complete replant survival in 16, partial survival

Figure 5. (a–c) Intraoperative images of 27-year-old female with total scalp avulsion after successful scalp replantation. [Color figure can

be viewed in the online issue, which is available at wileyonlinelibrary.com.]

Microvascular Approach 5

Microsurgery DOI 10.1002/micr

in three, and one failure.13 They advocated for the use of

at least two arteries and vein grafts to debride all possi-

bly injured vessels. Yin et al. reported a series of eight

patients of which three injuries were actually a result of

sharp amputation.14 There was only one case that resulted

in failure. This resulted from venous congestion as no

vein was performed owing to extensive injury to the flap.

They reported that the use of single or multiple arterial

anastomoses had little effect on successful outcomes;

rather, the venous outflow was the critical issue.

The LD flap (in various forms) was the most com-

monly used microvascular tissue transfer in our series

(65%). The LD muscle free flap, popularized by Maxwell

and Godina, can be used to cover large scalp defects.15,16

This flap can also be expanded as a combined flap for

very large defects or when one needs to reconstruct com-

posite tissue, such as skin, muscle, and bone.17–19 In our

series, the LD flap was combined with serratus, parascap-

ular, and split rib to address composite and more exten-

sive defects. For smaller defects, the latissimus can be

split longitudinally on a transverse intramuscular branch

of the thoracodorsal vessels to address ‘‘rectus muscle-

sized’’ defects. Our institution first described the latissi-

mus muscle flap as a partial superior latissimus flap,

thereby preserving form and muscle function.20 This

modification was used in two cases of smaller size

defects (150 cm2), one of which was used for innervated

reconstruction (using the thoracodorsal nerve) of lost

frontalis function with successful restoration. Preservation

of the cutaneous paddle over the anterior two-thirds of

the muscle is possible21; however, we generally prefer

split thickness skin grafts as coverage to allow the muscle

flap to atrophy over time and give a better overall aes-

thetic appearance in nonhair-bearing males. The large

size, predictable blood supply, long pedicle, versatility,

and ease of harvesting this flap make this our first choice

for scalp coverage when necessary.

We have also used a number of alternative free tissue

transfers to cover moderate to large sized defects. Partial

scalp tissue allotransplantation, omentum, radial forearm

fasciocutaneous, groin, and serratus flaps were included

in this series. Several authors have reported the use of al-

ternative flaps to cover moderate to large sized defects,

such as the anterolateral thigh flap, deep inferior epigas-

tric perforator flaps, and medial arm flaps with good

results.4,22–25

The omentum was used in one patient for a subtotal

defect after tumor extirpation. This microvascular flap is

ideal for large defects in highly irradiated wound beds.26

The major disadvantage is the donor site morbidity owing

to a midline laparotomy required to harvest the tissue.

Our institution first reported a pre-expanded twin–twin

scalp allotransplant tissue transfer in 1990 for reconstruc-

tion of a traumatic scalp defect that was partially treated

with replantation.27 Although composite tissue allotrans-

plantation (CTA) for the scalp in a nontwin donor has

Figure 6. (a, b) Twenty-seven-year-old female 1-year postoperative result after total scalp replantation. [Color figure can be viewed in the

online issue, which is available at wileyonlinelibrary.com.]

6 Herrera et al.

Microsurgery DOI 10.1002/micr

yet to be described, increasing understanding of immuno-

suppressive therapy and the development of CTA pro-

grams may pave the way for expanding microvascular

methods for treating scalp defects. Still, further refine-

ments may develop with the incorporation of improved

imaging and virtual planning technologies in secondary

reconstruction patients.28,29

CONCLUSIONS

The overall microvascular success rate in our series

was 92% which is consistent with the literature’s success

rates.30 Reconstruction of scalp defects can be challeng-

ing and many options exist based on the size of the

defect and etiology. In acute traumatic injuries, every

attempt should be made at replantation when the patient

is stable and the parts are salvageable. Larger scalp avul-

sion defects appear to have a greater success rates when

compared to smaller partial scalp avulsions (<300 cm2)

injuries. Free microvascular tissue transfers for secondary

scalp reconstruction remain a mainstay of treatment. LD-

based free muscle flaps are useful for this location with

high versatility for a range of defects and minimal mor-

bidity in skilled hands.

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